Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that two residents received adequate supervision and were protected from accident hazards, resulting in harm. One resident, who was dependent, cognitively impaired, and legally blind, sustained a left upper extremity fracture after accidental contact with a bed enabler during care. The facility did not identify the left bed rail as a potential hazard, despite the resident's significant physical and cognitive limitations. Documentation showed that the resident was dependent for all activities of daily living, required a Hoyer lift for transfers, and had a history of pain complaints, but there was no evidence that the risk posed by the bed enabler was adequately assessed or mitigated. Another resident, also severely cognitively impaired and dependent for all activities of daily living, experienced multiple falls over several months, including unwitnessed falls in various locations. The resident's care plan identified a high risk for falls but lacked person-centered interventions tailored to her needs. On one occasion, the resident was left unsupervised in a bathroom by a CNA who left to obtain an incontinent brief, resulting in a fall that caused a scalp laceration and a subtle sacral fracture. The CNA misrepresented the location and details of the incident, and the facility did not thoroughly investigate the true circumstances of the fall until 12 days later. Additionally, after the unwitnessed fall with a head injury, the facility failed to implement timely emergency interventions. The resident was not assessed by a registered nurse at the scene before being moved, and there was a delay of nearly three hours before the resident was sent to the emergency room. Interviews with staff revealed gaps in communication and documentation, as well as a lack of clear instructions for staff regarding supervision requirements for high-risk residents. The facility's documentation and care plans did not provide adequate guidance to prevent such incidents, despite the residents' extensive histories of falls and cognitive impairment.