Failure to Provide Adequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistive devices to prevent accidents, as evidenced by two residents who did not have their care planned interventions implemented. One resident, who was assessed and care planned for two-person assistance with an EZ stand lift for transfers, was transferred by a CNA who did not follow the manufacturer’s instructions. The safety strap on the harness was not fastened around the resident’s waist, and the transfer was attempted with only one staff member present. During the transfer, the resident began to slide through the straps and was lowered to the floor, resulting in a change in plane and reported shoulder pain. Multiple staff interviews confirmed that the safety strap was not used as required, and that the resident was not transferred according to her care plan, which specified two-person assistance. Another resident, who had a history of repeated falls and was assessed as a fall risk, was observed without his care planned fall prevention intervention in place. The resident’s care plan and Kardex specified that he should wear gripper socks at all times and not wear shoes due to a wound on his toe. However, the resident was observed in the dining room wearing regular socks, and a CNA admitted to attempting to put shoes on the resident, contrary to the care plan. The resident confirmed that his shoes caused a wound on his toe, and the CNA only provided gripper socks after the surveyor’s intervention. Staff interviews revealed a lack of awareness regarding the resident’s fall risk status and the required interventions. Facility policies required that residents be handled and transferred safely according to their individual care plans and that mechanical lifts be used according to manufacturer instructions. The policies also mandated that fall prevention interventions be implemented and monitored for effectiveness. In both cases, staff failed to follow established care plans and manufacturer guidelines, resulting in residents not receiving the necessary supervision and interventions to prevent accidents and falls.