Failure to Supervise Resident and Manage Meal Cart Hazard Resulting in Severe Hand Laceration
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free of accident hazards, resulting in a resident sustaining a significant right-hand laceration. The resident had multiple diagnoses, including heart disease, long-term use of anticoagulants, diabetes mellitus, major depressive disorder, anxiety disorder, morbid obesity, a need for assistance with personal care, a history of falling, muscle wasting, and fragile skin. Her care plan identified potential and actual impairment to skin integrity related to these conditions and documented that she required assistance or an escort to activity functions. Despite these identified needs, the resident was placed at the nurses’ station and later attempted to return to her room independently. On the date of the incident, nursing notes document that staff were called to the hallway and found the resident bleeding on the floor and from her hand. Assessment revealed a large skin tear and laceration on the right hand extending from the middle finger knuckles up between the second and middle finger to the wrist, with some areas too deep to approximate with steri-strips. The resident was transported to a local emergency room, where hospital records described a significant multilayer laceration exposing extensor tendons over the second and third metacarpals, measuring approximately 12 cm by 6 cm. The resident required 19 sutures, a nonstick dressing, and a splint to promote healing and prevent disruption of the sutures, and was started on antibiotics and narcotic pain medication. The facility’s root cause analysis and interviews show that the resident became entangled in a food tray cart while attempting to move herself from the nurses’ station back to her room without staff assistance. Another resident using a motorized wheelchair attempted to help by moving the food cart when he accidentally bumped his wheelchair controller, causing the chair to move and the first resident’s hand to become caught under the wheelchair controller, resulting in the laceration. Both the injured resident and the assisting resident reported that there were no staff present in the hallway at the time. The DON stated that staff usually push the injured resident back to her room after meals and that staff had placed her at the nurses’ station but were called away, and no staff observed that she was stuck in the tray cart. This sequence of events demonstrates that the resident was not adequately supervised in accordance with her assessed needs and the facility’s policy on accidents and supervision.
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