Failure to Prevent Accidents Due to Inadequate Supervision and Unsafe Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for three residents. One resident with severe cognitive impairment and a history of elopement was not assessed or care planned for safe vaping. The resident's baseline care plan and assessments did not address nicotine or vaping use, and the resident was found with multiple vapes at his bedside outside of supervised smoking times. Facility policy required all vaping materials to be secured and individualized plans for safe storage and supervision, but these were not implemented for this resident. Two other residents with severe cognitive impairment and dependence on staff for transfers were transferred unsafely by staff. In one case, two CNAs transferred a resident from a shower chair to bed by applying a gait belt too loosely and hooking their arms under the resident's arms, resulting in the resident's weight being supported by her arms rather than her legs. The staff were unaware of the increased risk of injury from this method and did not recognize the resident's non-weight bearing status as requiring a different transfer method. The care plan and Kardex were not updated to reflect the resident's needs, and staff did not follow safe transfer protocols as described by facility leadership. In another instance, two CNAs transferred a resident from a wheelchair to bed by grabbing her under the armpits and by the back of her pants, without using a gait belt. The resident was unable to assist with the transfer, and staff acknowledged that this method could lead to injuries. The staff were not certain of the resident's transfer status and did not have gait belts available at the time of transfer, despite facility policy requiring their use. Observations and interviews confirmed that staff did not follow established safe transfer procedures, and documentation indicated the resident was totally dependent on staff for transfers.