Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision for a cognitively impaired resident with a high risk for falls. The resident, who had severe cognitive impairment, bilateral hip osteoarthritis, osteoporosis, schizoaffective disorder, vascular dementia, muscle weakness, lack of coordination, and right eye blindness, required substantial to maximal assistance with transfers and was care planned for two-person assistance. There was no documentation indicating the use of a mechanical lift for transfers, despite this being required. On the day prior to the resident's hospital transfer, staff observed the resident had pain and dark discoloration on the buttocks during repositioning for perineal care. The resident reported having fallen, but could not provide details. Staff did not complete a skin assessment as required, and there was no documentation of an accident or incident prior to the discovery of the injury. The resident was later found to have an acute, displaced femoral fracture and was sent to the hospital for surgery. Multiple staff interviews revealed inconsistent knowledge and practices regarding the resident's transfer status, with some staff relying on verbal reports or outdated lists rather than the care plan or electronic medical record (EMR). Further interviews indicated that staff, including CNAs and nurses, were not consistently following the facility's fall protocol when a cognitively impaired resident reported a fall or presented with a new skin issue. The facility's policies required notification of the physician and responsible party, completion of assessments, and documentation of incidents, but these steps were not followed. The resident's roommate reported that staff often used only one-person assistance for transfers, and there was uncertainty among staff about the proper use of mechanical lifts. There was also a lack of in-service training related to fall protocol, transfers, and accident/incident management during the relevant period.