Failure to Provide Adequate Supervision and Follow Care Plans
Penalty
Summary
Staff failed to provide adequate supervision and follow resident care plans in two separate incidents involving two residents. In the first incident, a resident with moderate cognitive impairment was left unsupervised in a whirlpool tub after a miscommunication between CNAs and a charge nurse. The resident's care plan required staff to remain in the room during bathing, but the last CNA present left the resident alone, assuming another staff member would take over. The resident was only able to call for assistance by yelling, as there was no call light or other means to alert staff. Staff interviews confirmed that facility policy and training required residents not to be left alone in the whirlpool tub, regardless of their level of independence. In the second incident, a resident with severe cognitive impairment and a high risk for falls was left standing unattended by her dresser while a CNA turned down her bed linens. The resident fell backward, sustained a head injury, and required evaluation at the emergency department. The care plan for this resident specified standby assistance with a walker and that staff should remain within arm's reach due to her fall risk. The CNA involved was uncertain about the required level of assistance at the time and did not ensure the resident was in a safe position before attending to other tasks in the room. Both incidents were attributed to failures in communication, staff assumptions, and lack of adherence to individualized care plans and facility policies. The facility's policies on bathing and fall prevention required staff to remain with residents during bathing and to provide supervision based on assessed needs, but these were not followed in the cases described. The residents involved had documented cognitive impairments and required specific levels of assistance and supervision, which were not provided at the time of the incidents.