Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that residents received adequate supervision to prevent accidents for two residents reviewed for quality of care. For one resident with severe cognitive impairment, right-sided hemiparesis, and a history of falls, the call light was not within reach, assist bars were not in place, and the bedside table was positioned away from the resident. This resident required maximal assistance for bed mobility and had documented interventions for fall risk, including the use of assistive devices and call light placement. On the day of the incident, the resident was found on the floor after an unwitnessed fall from bed, with subsequent pain and abrasions, and was sent to the hospital for evaluation. Observations and interviews confirmed that the call light was not accessible and the bedside table was not appropriately positioned, contrary to the care plan and facility policy. Another resident, who was cognitively intact but required substantial assistance for bed mobility due to morbid obesity, osteoarthritis, and COPD, did not have a PT/OT evaluation completed for the use of assist bars after new beds were installed. This resident had previously used bed rails to assist with mobility and reported a loss of independence after their removal. The facility had not completed the required side rail assessment or therapy evaluation to determine the need for assist bars, resulting in the resident waiting for staff assistance for bed mobility. Interviews with staff and the resident confirmed that the lack of assist bars affected the resident's ability to move independently in bed. Facility staff interviews revealed that the process for evaluating and installing assist bars was delayed due to the arrival of new beds and pending therapy assessments. Maintenance staff were waiting for therapy's list before installing assist bars, and clinical leadership acknowledged that therapy evaluations were progressing slowly. The facility's policies required individualized assessments and interventions for fall prevention and side rail use, but these were not consistently implemented for the affected residents, leading to unmet care needs and increased risk for accidents.