Failure to Prevent Accidents and Address Behavioral Hazards
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident with Parkinson's Disease, cognitive impairment, and significant dependence on staff for activities of daily living experienced two falls while being transported in a wheelchair without footrests. In both incidents, the resident placed their feet on the floor while being pushed, resulting in falls—one of which led to a hematoma and complaints of pain, requiring an emergency room visit. Staff and therapy notes confirmed that the absence of footrests contributed to both falls, and staff were aware that the resident had difficulty keeping their feet on the footrests and tended to lean forward in the wheelchair. Another resident with dementia, behavioral disturbances, and a history of agitation and trauma exhibited ongoing wandering, agitation, and aggressive behaviors, including altercations with other residents. Despite documentation of these behaviors and a care plan update following an initial incident, no new interventions were added to address the resident's increased wandering and aggression. This lack of additional interventions resulted in continued disruptive and aggressive behavior, including a physical altercation with another resident in a wheelchair.