Failure to Prevent Accidents Due to Inadequate Supervision and Staff Training
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions to prevent accidents for two residents. In the first incident, a resident who was dependent for transfers and required the use of a mechanical lift with two staff members was transferred by a single CNA without assistance. The CNA did not lock the Geri-recliner or open the base of the lift, resulting in the resident falling to the floor and sustaining a rib fracture. Both CNAs involved had received training indicating that two staff were required for mechanical lift transfers, but the procedure was not followed, and the incident was confirmed by interviews and documentation. In the second incident, another resident was being transported back to the facility from a hospital in a wheelchair via the facility van. During transport, the wheelchair moved and tilted backward, causing the resident, still in the wheelchair, to fall onto the floor of the van. The CNAs responsible for the transport had not received formal training or competency checks for the use of the van's securement system. The DON provided only a verbal explanation of the securement process without demonstration or requiring return demonstration. The resident did not sustain injury, but the event was reported and confirmed by the resident, staff, and documentation. Both incidents involved residents with significant medical histories and physical impairments. The first resident had acute respiratory failure, lack of coordination, osteoporosis, and was dependent for transfers. The second resident had acute kidney failure, cognitive communication deficit, vascular dementia, and muscle weakness, and required a wheelchair for mobility. The deficiencies were directly related to staff not following established policies and lack of adequate training or supervision during critical procedures, resulting in preventable accidents.