Failure to Provide Required Supervision and Assistive Equipment During Care
Penalty
Summary
A deficiency occurred when a resident with significant cognitive and physical impairments, including hemiplegia, traumatic brain injury, aphasia, and a history of falls, was not provided with adequate supervision and assistive equipment during incontinent care. The resident's care plan and physician orders specified the need for two-person assistance for bed mobility and toileting, as well as the use of bilateral bedrails for safety. However, on the date of the incident, only one staff member assisted the resident, and the bed was not equipped with the required side rails. During care, the resident rolled off the bed and sustained a minor injury, with bleeding noted from the mouth. Documentation related to the incident was incomplete, lacking immediate witness statements and clear identification of the staff involved. Interviews confirmed that the staff member was alone during the incident and that side rails were not in place, contrary to the care plan and physician orders. The Director of Nursing and Administrator were made aware that established interventions for fall prevention and safe care were not followed at the time of the incident.