Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate oversight and prevent injury for two residents, resulting in significant harm. One resident, who had diagnoses including dementia, muscle weakness, reduced mobility, and was dependent on staff for all transfers, was injured during a transfer when staff manually moved the resident due to a malfunctioning electronic bed. The mechanical lift could not be used because the bed would not raise, and staff proceeded with a two-person manual transfer. During this process, the resident sustained a large open laceration to the left lower extremity, which required emergency medical care, including sutures, antibiotics, pain management, and wound care. Documentation and staff statements indicated that the injury likely occurred when the resident's leg caught on the wheelchair pedal, which had not been removed prior to the transfer, contrary to safe transfer practices outlined in the care plan. Another resident, with a history of dementia, Alzheimer's disease, and wandering, experienced an elopement that resulted in a fall with injury. The resident was known to require a wander guard and supervision due to increased confusion and wandering behavior. On the day of the incident, the resident was able to exit the building and was found outside by a pharmacy delivery driver, who later discovered the resident had fallen in the parking lot. Staff interviews and written statements revealed that the door alarm, which was intended to alert staff to unauthorized exits, was either not heard by staff or was not loud enough to be effective throughout the building. Multiple staff members reported not hearing the alarm, and the resident was able to leave the building unsupervised, resulting in abrasions and complaints of pain that required hospital evaluation. In both cases, the facility did not ensure that safety measures and supervision were effectively implemented according to the residents' care plans and needs. The lack of proper use of equipment, failure to follow transfer protocols, and insufficient monitoring of exit alarms directly contributed to the residents' injuries. The report documents that these deficiencies were identified through observation, interview, and record review, and that the facility did not have adequate policies or practices in place to prevent such incidents at the time they occurred.