Failure to Prevent Accidents Due to Lack of Equipment and Supervision
Penalty
Summary
The facility failed to provide appropriate equipment and supervision to prevent accidents for two residents, resulting in actual harm. One resident with severe cognitive impairment and a history of right foot fracture was transported in a wheelchair without footrests by nursing assistants. During transport, the resident's foot dropped to the floor, her shoe came off, and she sustained a bruise and an acute fracture of the right fifth toe. Staff interviews revealed a lack of awareness and inconsistent use of wheelchair leg rests, with some staff stating they would ask residents to hold their legs up if footrests were unavailable. Observations confirmed multiple residents being pushed in wheelchairs without leg rests, and the DON acknowledged that staff were not informed about which residents required leg rests, relying instead on whether the equipment was present on the chair. Another resident, who was cognitively intact but required two-person assistance for bed mobility due to an air mattress, was left unattended by a nursing assistant during care. The assistant placed the resident near the edge of the bed in a lateral position and stepped out of the room to consult with a nurse, leaving the resident unsupervised. The resident subsequently rolled out of bed, sustaining a hematoma and laceration above the left eye, a hematoma to the right knee, and reported pain. Documentation and staff interviews confirmed that the resident's care plan and assignment sheet specified the need for two-person assistance, but the nursing assistant was unaware of this requirement despite having access to the assignment sheet. Facility policies required maintaining an environment free from accident hazards and providing adequate supervision and assistive devices. However, the facility did not ensure staff were aware of or followed these requirements, resulting in residents being exposed to preventable harm. Staff interviews and observations highlighted gaps in communication and adherence to care plans, directly contributing to the incidents of injury.