Failure to Prevent Accidents and Update Care Plans Following Resident Incidents
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with severe cognitive impairment. In the first case, a resident with end-stage renal disease, syncope, vascular dementia, and bradycardia, who was dependent for transfers and had a history of falls, was transported to dialysis in the facility van. Despite prior incidents where the resident had unbuckled her seatbelt or attempted to stand during transport, these behaviors were not documented in her care plan, and no interventions were implemented to address them. Staff, including the van driver and activity director, were aware of these behaviors but did not consistently report them to nursing or administration, and no team meeting was held to discuss or address the risk. As a result, the resident unbuckled her seatbelt during transport, fell from her wheelchair, and sustained a laceration to her forehead, requiring emergency medical attention. In the second case, another resident with severe vascular dementia and schizoaffective disorder, who required substantial assistance for transfers, experienced an unwitnessed fall from her low bed, resulting in a right knee patella fracture and a skin tear. Although interventions such as a floor mat and low bed were in place, the resident was able to manipulate the bed controller, raising the bed and increasing her risk of falling. Staff interviews revealed that the resident had a history of moving the bed out of the lowest position by pressing buttons on the controller, but this risk was not addressed in her care plan. After the fall, the care plan was not updated to include new interventions or to reflect the changes in the resident's condition, despite facility policy requiring immediate care plan revision after such incidents. In both cases, the facility did not identify or address known hazards and risks in the residents' environments, failed to update care plans with necessary interventions, and did not ensure that staff communicated and documented unsafe behaviors or incidents. These failures resulted in preventable accidents and injuries, and the lack of care plan updates meant that staff may not have been aware of the residents' specific risks or the interventions needed to prevent further incidents.