Failure to Prevent Accident Hazards and Ensure Supervision Resulting in Resident Harm
Penalty
Summary
The facility failed to identify and eliminate accident hazards and did not provide adequate supervision to prevent a serious fall and injury for a resident with a history of repeated falls, impaired cognition, and significant physical limitations. The resident, who was dependent on staff for transfers and used a wheelchair for mobility, was left unattended in her room in her wheelchair, contrary to multiple care plan interventions that specified she should not be left alone in this situation and should be monitored closely at the nurse station or dayroom. Despite these documented interventions, staff left the resident unsupervised, resulting in an unwitnessed fall where her right arm became lodged in the wheel of the wheelchair, causing a large avulsion wound that required hospital transfer and surgical repair. Review of facility policies and the resident's care plan revealed clear directives for staff to provide close monitoring, avoid leaving the resident unattended in her wheelchair, and to document frequent checks, especially given her high fall risk and cognitive impairment. Multiple staff interviews confirmed that the resident was left alone in her room in her wheelchair, and that monitoring and documentation of supervision were not consistently performed as required by the care plan. Additionally, the facility's investigation did not address the role of the wheelchair in the incident, nor did it include measurements of the injury, and there was no evidence that the care plan was updated to address the identified hazards related to wheelchair use. Staff actions following the fall also deviated from facility policy, as a CNA removed the resident's arm from the wheelchair wheel before a licensed nurse assessed the injury, which was not in accordance with the facility's protocol for post-fall assessment. Interviews with the DON and other staff revealed a lack of clarity and consistency in monitoring practices, documentation, and adherence to care plan interventions. The facility did not provide documentation of required 30-minute monitoring checks, and there was no evidence of a performance improvement plan following the incident. These failures resulted in actual harm to the resident.