Failure to Provide Adequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate supervision and implement safety measures for two residents, resulting in accident hazards and increased risk of injury. One resident with severe cognitive impairment and a history of falls experienced a fall from bed during personal care. The CNA providing care left the resident unattended on the bed while changing gloves, during which time the resident rolled off the bed and sustained a head injury with a large hematoma and bleeding. The resident was on anticoagulant therapy, which was not communicated to emergency services by facility staff. Prior to this incident, the resident had a previous fall with injury, but no additional fall prevention interventions were implemented until after the second fall. The care plan was not updated with appropriate interventions such as floor mats and bed wedges until after the injury occurred. Staff interviews revealed that the CNA assigned to the resident had limited experience, having only worked in the facility for a few months and often worked alone despite being assigned a high number of residents. The CNA reported difficulty working in pairs due to staffing levels, and on the night of the incident, each CNA was responsible for 14 residents. The DON and Risk Manager acknowledged that there was a gap in communication regarding the implementation of fall prevention interventions after the first fall, and that a physician's order was required for certain safety devices, which contributed to the delay in implementing these measures. In a separate incident, another resident was left at risk of falling during personal care when staff failed to properly use fall prevention devices. During morning care, one CNA left the room while the other continued care, leaving the resident near the edge of the bed with the side padding/wedge down. The CNA admitted to forgetting to raise the side wedge and not positioning the resident in the middle of the bed as required. The unit manager confirmed that staff should not have left the side wedge down and should have called for help if needed. Both incidents demonstrate a failure to maintain an environment free from accident hazards and to provide adequate supervision and use of assistive devices as required by facility policy.