Failure to Prevent Accidents Due to Inadequate Supervision and Unsafe Practices
Penalty
Summary
The facility failed to ensure that all residents received adequate supervision and that the environment was free from accident hazards, resulting in multiple incidents involving resident harm. One resident, who required staff assistance for feeding and was unable to feed herself, was given reheated coffee by a CNA who did not check the temperature before serving. The resident spilled the coffee, resulting in scalding burns to her torso, abdomen, and right breast, which required hospitalization in a burn unit for wound and pain management. Another resident, who was at risk for falling due to spastic quadriplegic cerebral palsy and required a two-person assist for transfers, fell from his bed and sustained a head laceration requiring sutures. This occurred when a CNA raised the resident's bed in preparation for a transfer and then left the room to retrieve a Hoyer lift, leaving the resident unattended in an elevated position. The resident rolled out of bed during this time, resulting in injury. A third resident, who required maximum assistance with stand pivot transfers and the use of a gait belt, experienced a fall during a staff-assisted transfer. The CNA responsible for the transfer did not lock the resident's wheelchair before initiating the transfer, causing the wheelchair to slip out from under the resident. The resident fell and sustained a bruise to the lower back. In each case, staff failed to follow established protocols for resident safety and supervision, directly leading to resident injuries.