Failure to Prevent Accidents Due to Inadequate Supervision and Assistive Devices
Penalty
Summary
Facility staff failed to ensure that two residents received appropriate assistance and assistive devices to prevent accidents. For one resident with hemiplegia, dementia, generalized muscle weakness, and a history of falls, staff used an incorrectly sized mechanical lift pad and performed a transfer with only one staff member instead of the required two. During the transfer, the resident slipped from the lift pad and fell to the floor. The staff member then moved the resident from the floor to the bed before a nurse could assess for injuries, contrary to facility policy. The resident was dependent on staff for transfers and was care planned for two-person assistance with a mechanical lift and the correct size lift pad, but these interventions were not followed at the time of the incident. Another resident, who had diagnoses including traumatic subdural hemorrhage, Parkinsonism, dementia, and repeated falls, did not have Dycem non-slip material in the wheelchair as specified in the care plan. This resident was severely cognitively impaired, dependent on staff for transfers, and had a recent history of multiple falls. During multiple observations, the resident was seen transferring independently and walking without assistance, and the required Dycem was not present in the wheelchair. Staff were unaware of the missing Dycem and could not provide an explanation at the time of the survey. Facility policies required at least two staff for mechanical lift transfers and the use of properly sized lift pads, as well as individualized fall prevention interventions. In both cases, staff did not follow established protocols and care plan interventions, resulting in preventable incidents involving residents at high risk for falls and injury.