Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents, as evidenced by multiple incidents involving several residents. One resident, who had a history of muscle weakness, difficulty walking, and moderate cognitive impairment, required two staff for safe transfers according to their care plan and Kardex. Despite this, the resident was transferred by a single staff member, resulting in a severe laceration to the leg that required 15 sutures. The injury was caused by the resident's leg hitting an uncapped edge of the bed frame during the improper transfer. The staff member involved did not follow the care plan, and the incident was reported as an injury of unknown source before the cause was determined. Another resident with severe cognitive impairment, a history of falls, and dependence on staff for mobility experienced multiple unwitnessed falls over several months. The care plan included interventions such as keeping the call light within reach, frequent checks, and supervision at the nurses' station. However, the resident was repeatedly found alone in their room or in other areas without adequate supervision, leading to several falls, some resulting in injuries such as skin tears and a possible clavicle fracture. Staff interviews revealed that the resident was unable to use the call light effectively and could not remember instructions, yet was left unsupervised on multiple occasions. Staff also acknowledged that interventions like visual cues and education were ineffective due to the resident's cognitive status. Incident reports and post-fall investigations were often incomplete, lacking details about the circumstances leading to the falls, when the resident was last seen, and what interventions were in place at the time. Staff interviews confirmed that required documentation and witness statements were not consistently obtained, and that there was no clear assignment of responsibility for supervising high-risk residents at the nurses' station. These failures in supervision, adherence to care plans, and thorough investigation contributed to an environment where accident hazards were not minimized, directly resulting in harm and repeated incidents for multiple residents.