Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that three residents were free from accident hazards and provided with adequate supervision and assistance devices to prevent accidents, resulting in three avoidable falls, two of which caused major injuries. In one case, a resident with hemiplegia and a history of cerebral infarction required extensive assistance for bed mobility and personal care. During peri-care, a CNA turned away from the resident to dispose of a soiled brief, leaving the resident unattended. The resident, unable to control movement due to hemiplegia, rolled out of bed and sustained a displaced fracture of the right femoral neck and a laceration to the forehead. In another incident, a resident dependent on a mechanical lift (Hoyer) for transfers due to multiple sclerosis was being transferred by two CNAs. The staff failed to open the legs of the Hoyer lift because of space constraints in the resident's room, which was too small to allow proper maneuvering. As a result, the resident slipped out of the sling and fell to the floor, sustaining an abrasion to the upper back. The care plan for this resident specified total dependence on two staff for Hoyer transfers and highlighted the need for adequate space and proper use of equipment. A third resident suffered a fall with major injury during wheelchair transport when a CNA failed to attach footrests to the wheelchair. The resident, who was unable to lift their legs, fell forward from the wheelchair and sustained a nasal bone fracture. Facility policy and posted signage required the use of footrests during all wheelchair transports to prevent injury, but this protocol was not followed, directly leading to the fall.