Resident Harm Due to Lapse in Supervision and Incomplete Bed Safety Assessment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of falls was not provided an environment free from neglect and physical harm. The resident, who was at high risk for falls and had multiple medical conditions including dementia and diabetes, was found on the floor with his left arm entrapped between the bed and bed rail. The incident resulted in a significant injury, specifically an arterial tear to the left arm, which required surgical intervention. The sequence of events leading to the deficiency involved a lapse in supervision and failure to follow established protocols for resident checks and shift handoff. The nurse aide assigned to the resident left the facility without notifying the supervising nurse, and the oncoming aide was delayed and did not arrive as scheduled. As a result, the resident was not checked for over two hours, contrary to the facility's expectation of checks at least every two hours. When the resident was eventually found, his bed was observed to be higher than normal, both bed rails were up, and his call light and bed remote were on the floor, further contributing to the risk of harm. Additionally, documentation revealed that a bed safety evaluation had not been fully completed, with specific steps regarding risk factor evaluation and checking for zones of entrapment left blank. Although the resident had been assessed as a fall risk and care planned accordingly, these lapses in supervision, incomplete safety assessments, and failure to ensure proper shift-to-shift communication directly contributed to the resident's injury.