Failure to Prevent Resident Fall and Remove Environmental Hazard
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident with severe cognitive impairment and a history of repeated falls. During morning care, a CNA turned her back to the resident to obtain a washcloth, at which point the resident, known to have jerking movements, fell from the bed. The resident sustained a laceration to the forehead requiring sutures and, two days later, was found to have swelling and limited range of motion in the left leg. An x-ray revealed a displaced fracture of the left femur. The resident's responsible party, after consultation with the physician, opted for comfort care due to the resident's poor surgical candidacy and advanced dementia. The resident subsequently expired in the facility. The facility also failed to identify and remove an accident hazard in a resident's room on the dementia unit. Broken glass was observed in a picture frame in the restroom of a resident with severe cognitive impairment. Although a staff member observed the broken glass, no action was taken to remove it. The glass remained in the room, posing a risk to the resident and others, including wandering residents who could enter the room. Interviews confirmed that staff were aware of the hazard but did not report or address it in a timely manner. Facility policy required all staff to be involved in identifying and addressing environmental hazards and to provide adequate supervision to prevent accidents, taking into account each resident's unique needs. In both incidents, staff failed to follow these protocols: in the first case, by leaving a dependent resident unsupervised during care, and in the second, by not removing a known environmental hazard. These failures resulted in actual harm to one resident and the potential for harm to others.