Failure to Prevent Accidents Due to Inadequate Supervision and Environmental Hazards
Penalty
Summary
The facility failed to identify and mitigate environmental hazards, ensure the appropriate use of assistive devices, and implement care planned interventions, resulting in falls and injuries for three residents. One resident with moderate cognitive impairment and a history of independent ambulation sustained multiple lower leg fractures requiring surgical intervention after slipping on a wet floor while exiting the bathroom post-shower. The resident was barefoot, without a gait belt or non-skid footwear, and the CNA assisting her did not attempt to use a shower chair or other safety devices, assuming the resident would refuse them based on prior behavior. The incident occurred as the resident lost her balance on the floor transition, which was wet from the shower, and fell backward, resulting in an open fracture confirmed by emergency services. Another resident with severe cognitive impairment and mobility issues fell in the shower while being assisted by a CNA. The resident attempted to transfer from a wheelchair to a shower chair, but the shower chair was not properly locked, the floor was wet, and the resident was barefoot without a gait belt. The CNA admitted to forgetting to lock the wheels and not placing a towel on the ground, and the water was running at the time of the fall, making the floor slippery. The care plan for this resident required contact guard assistance with a gait belt and walker for transfers, but these interventions were not implemented at the time of the incident. A third resident with Alzheimer's disease and a history of repeated falls was found on the floor with a right femur fracture and lumbar compression fracture. The care plan included the use of a bed alarm to alert staff when the resident was getting out of bed, but the alarm was not turned on at the time of the fall. Staff interviews confirmed that the bed alarm was in place but not activated, likely due to oversight by the night shift CNA. The facility's policy required the environment to remain as free of accident hazards as possible and for residents to receive adequate supervision and assistive devices, but these measures were not consistently implemented, leading to actual harm.