Failure to Ensure Resident Safety and Proper Supervision
Penalty
Summary
The facility failed to maintain a safe environment for a resident with dementia, who was at risk for falls due to gait and balance issues. Despite being educated by staff on the importance of using the call bell for assistance, the resident continued to self-ambulate. On one occasion, the resident fell while attempting to self-transfer to the bathroom, and there were no new interventions implemented to prevent such incidents prior to the fall. Additionally, the resident mistakenly used Calmoseptine on her dentures instead of denture cream, indicating a lack of supervision and proper management of personal care items. Although a new intervention was suggested to remove bedside creams, this was not documented in the care plan, and the Calmoseptine remained accessible in the resident's bathroom. Interviews with staff confirmed these oversights, highlighting a failure to adequately address the resident's safety and care needs.
Plan Of Correction
The facility cannot retroactively correct the fall interventions but has corrected the care plan for resident R8. A year to date audit of incidents reports will be conducted to confirm suggested interventions have been initiated. All nursing staff, including agency staff and new hires will be educated on the facility care plan policy and procedures. Administrative nursing staff will be educated on the accidents and incident process. The 24-hour clinical nursing report will be reviewed by Director of Nursing or designee, daily for 2 weeks followed by random audits for 2 weeks. Five accidents and incident reports will be reviewed weekly times 4 to confirm interventions are in place. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.