Failure to Prevent Accident Hazards and Provide Safe Supervision
Penalty
Summary
The facility failed to ensure that accident hazards were removed and that adequate supervision was provided to prevent accidents, resulting in significant injuries to two residents. In one instance, a resident was pushed in a wheelchair by her Power of Attorney during an outdoor event without the foot pedals properly installed. The foot pedals were off to the side, leaving the resident's legs exposed and unsupported. Staff observed the improper use of the wheelchair foot pedals but did not intervene or provide assistance. As a result, the resident's foot became caught when transitioning from pavement to grass, leading to a fall and a left leg fracture. In another case, a resident with a history of falls and requiring assistance for transfers attempted to go to the bathroom independently during the night. The resident tripped over oxygen tubing and a call light cord that were stretched across the room, both identified as environmental trip hazards. The resident fell and sustained a right hip and right arm fracture. Staff interviews confirmed that the room setup contributed to the fall, as the cords were not secured or arranged to prevent tripping. Following the fall, staff did not use appropriate transfer techniques to move the injured resident. Instead of using a full mechanical lift or waiting for emergency services, staff lifted the resident by her shoulders and legs, causing her to scream in pain. This method of transfer was not in accordance with proper post-fall procedures, especially given the resident's injuries and inability to bear weight. The facility's failures in identifying and addressing environmental hazards, as well as improper transfer techniques, directly resulted in harm to the residents.