Failure to Prevent Accidents Due to Inadequate Supervision and Noncompliance with Care Plans
Penalty
Summary
The facility failed to ensure that three out of five residents received adequate supervision and assistive devices to prevent accidents, as evidenced by multiple observations, interviews, and record reviews. One resident sustained a left femur fracture when a CNA transferred the resident alone using a sit-to-stand lift, despite care instructions requiring two staff for transfers. The lift lost power during the transfer, and the resident's leg gave out, resulting in a fracture. Following the incident, the resident was observed multiple times without the required leg brace, and staff were seen operating the mechanical lift incorrectly, including not supporting the resident's injured leg and not following proper lift procedures. Additionally, a physician-ordered follow-up x-ray was not obtained, and documentation indicated staff were marking the x-ray as completed when it was not. Staff training on lift use was incomplete, and agency staff did not receive competency evaluations. Another resident, who is severely cognitively impaired and dependent for care, was observed repeatedly without a floor mat at the bedside, contrary to the care plan and CNA worksheet instructions. The floor mat, intended as a fall prevention measure, was found folded and not in use during multiple observations across different shifts. Staff did not place the mat at the bedside during or after care, and when questioned, a CNA stated she had not moved the mat. The issue was brought to the attention of nursing management, but the mat remained unused at the resident's bedside throughout the survey period. A third resident, also severely cognitively impaired and at risk for falls, was not toileted after meals as required by the fall prevention care plan. The resident was observed self-transferring to the toilet without staff assistance, despite being care planned for substantial assistance with transfers and toileting. Staff did not follow the intervention to toilet the resident after meals, and the resident was found on the toilet by a CNA, who then instructed the resident not to self-transfer in the future. The failure to follow the toileting intervention was confirmed by staff interviews and direct observation.