Failure to Prevent Accidents Due to Improper Equipment Use and Inadequate Supervision
Penalty
Summary
Staff failed to ensure the safety of three residents who experienced falls related to improper use of equipment. In one instance, a certified nurse aide (CNA) did not secure a safety belt on a bath chair while a resident was seated, resulting in the resident falling forward onto the floor after being moved out of the whirlpool bathtub. The resident sustained a head laceration, nosebleed, and was later found to have cervical fractures. The CNA involved had previously signed an education sheet confirming receipt of training on proper equipment use, including securing safety belts, just three days prior to the incident. However, the CNA stated she was unaware of the requirement to use the seat belt. Following the fall, there were discrepancies in the accounts provided by the registered nurses (RNs) who responded to the incident, and it was unclear whether the resident was appropriately repositioned. The resident was moved with a Hoyer lift to a wheelchair before emergency medical services arrived, despite facility policy indicating that residents with suspected major injuries should not be moved. Additionally, there was no documented neurological evaluation completed after the fall, contrary to facility policy requiring such assessments for falls involving head trauma. In two other incidents, staff failed to use required safety straps during transfers with mechanical lifts. One resident fell from a sit-to-stand lift when the leg straps were not used, resulting in pain and hospital evaluation. Another resident fell from a bath chair after the seatbelt was removed and not replaced, and the chair's wheels were not locked. In both cases, staff were aware of the safety requirements but did not follow them. Care plans were not updated following these incidents as expected. Facility policies and manufacturer instructions required the use of safety belts and locking of wheels during equipment use, but these were not consistently followed.