Failure to Provide Adequate Supervision and Safe Resident Handling
Penalty
Summary
Staff failed to provide adequate supervision and follow established policies and procedures to maintain resident safety on a secure care unit. On one occasion, two residents were left unsupervised in the dining room when a staff member left to put dishes away in the kitchen, and another staff member left the area to use the restroom. During this period without supervision, one resident pulled another resident's wheelchair, causing the resident to fall to the floor. No staff were present in the immediate area to intervene or prevent the incident, as confirmed by video footage reviewed by facility leadership. The resident who fell was initially assessed and found to have no injuries, but was later discovered to be in significant pain and was transferred to the hospital, where a hip fracture was diagnosed and surgically repaired. The incident revealed that staff did not adhere to the facility's policies regarding supervision and safe resident handling. Staff interviews indicated that there should have been at least two CNAs present for constant supervision, and that staff are expected to have another staff member replace them if they need to leave the unit. However, these protocols were not followed, resulting in a lapse in supervision. Additionally, after the fall, staff manually transferred the injured resident from the floor to a wheelchair without using a gait belt, despite gait belts being available on the unit and required by facility policy for safe transfers. This manual transfer was performed by supporting the resident under the arms and holding the back of his pants, which was not in accordance with the facility's safe handling policy. A separate incident involved a physical altercation between two other residents on the secure care unit, which also occurred when staff supervision was lacking. In this case, a staff member failed to notify a supervisor before leaving for a lunch break, resulting in residents being left unsupervised and leading to a resident-to-resident altercation. Documentation and interviews confirmed that the staff member did not follow instructions for one-to-one supervision, contributing to the occurrence of the incident.