Failure to Prevent Accidents During Staff-Assisted Care
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, who was dependent on staff for all activities of daily living and mobility, was not provided with necessary and adequate care to prevent accidents during staff-assisted care. The resident, who had diagnoses including unspecified dementia, Alzheimer's disease, and osteoarthritis, was at high risk for falls and required a Hoyer lift for all transfers. Despite this, staff failed to ensure the resident's foot was not caught under her wheelchair while being transported, resulting in a fractured distal medial femoral metadiaphysis. Multiple CNAs reported that the resident did not have leg rests on her wheelchair, her feet would drag on the ground during transport, and it was common knowledge among staff that she would not lift her feet, yet leg rests were not provided until after the injury occurred. A second incident occurred when staff failed to properly secure the resident in a Hoyer lift during a transfer. Two CNAs were present and attempted to transfer the resident from bed to chair using the Hoyer lift, but the sling was not positioned correctly under the resident. As a result, the resident slid out from the feet end of the Hoyer pad and fell to the floor, sustaining a fracture to her right upper extremity/elbow. Interviews with staff revealed uncertainty about the correct placement of the Hoyer pad, and one LPN noted that the pad was not down far enough to support the resident's hips and buttocks, possibly due to the immobilizer on her leg from the previous injury. The incidents were confirmed through medical record review, staff interviews, and facility investigations. The resident's care plan indicated the need for leg rests and use of a Hoyer lift for all transfers, but these interventions were not consistently implemented by staff. The lack of adherence to the care plan and failure to provide necessary equipment and supervision directly led to the resident sustaining two significant injuries during routine care activities.