Failure to Prevent Accidents Due to Inadequate Supervision and Assistance
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents for two residents, resulting in actual harm to one. One resident, with a history of cerebral infarction, pulmonary embolism, and severe cognitive impairment, required total assistance for activities of daily living and specifically needed two staff members for bed mobility and transfers. Despite this, a certified nurse aide provided care alone during incontinence care, which led to the resident falling from bed. The resident was later found with multiple injuries, including a contusion to the right face, right elbow, a forehead laceration, and was subsequently diagnosed at the hospital with an acute intertrochanteric right femur fracture. The investigation confirmed that the fall occurred when only one staff member assisted the resident, contrary to the care plan and documented requirements. Another resident, diagnosed with Alzheimer's disease, diabetes, and dementia, was identified as being at high risk for falls and had a care plan requiring one-hour safety checks and supervision. On the day of the incident, there was no documented evidence that hourly safety checks were performed during a specific shift, and the resident was found on the floor after an unwitnessed fall from their wheelchair. Observations also revealed that the resident was left unsupervised in the day room, sliding forward in their wheelchair with the chair alarm activated, while no staff were present to supervise due to other duties or absences. Interviews with staff confirmed lapses in following the care plans, including failure to perform and document required safety checks and lack of clarity regarding supervision responsibilities in the day room. Staff acknowledged awareness of the residents' high fall risk but did not consistently implement or document the required interventions. The Director of Nursing was unaware of the incomplete safety check log at the time of the incident, and staff involved in the incidents either failed to follow established protocols or did not ensure proper documentation and supervision.