Failure to Provide Adequate Supervision and Safe Transfers Resulting in Resident Falls and Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and ensure a safe environment for a resident with multiple risk factors, including morbid obesity, dementia, decreased mobility, and a history of falls. The resident was dependent on staff for transfers, bathing, and mobility, and required the use of a mechanical lift and two-person assistance for safe care. Despite these needs, there were multiple incidents where staff did not follow established protocols or manufacturer's recommendations, resulting in accidents. In one incident, a nurse aide left the resident unsupervised in a shower chair that was not the resident's preferred type, as it did not allow her feet to touch the floor, compromising her sense of balance. The aide turned away twice to gather supplies, and during the second instance, the chair tipped forward, causing the resident to fall onto the shower floor. Although no injury was noted from this fall, the event highlighted a lack of supervision and disregard for the resident's expressed concerns about the equipment being used. In a separate event, the same resident was transferred from bed to wheelchair using a mechanical lift by a single nurse aide, despite facility policy and training that required two staff members for such transfers. During the transfer, the lift tilted and the resident fell to the floor while still in the sling, and the lift itself fell on top of her, resulting in a left calcaneal fracture and a left anterior talus fracture. Additionally, there were observations of staff using slings that did not match the brand of the mechanical lift, contrary to manufacturer instructions, and staff were responsible for determining sling size without clear oversight. These failures in supervision, adherence to protocols, and equipment compatibility directly led to resident harm.