Inadequate Supervision and Environmental Safety in LTC Facility
Penalty
Summary
The facility failed to implement effective interventions and provide adequate supervision to prevent repeated falls for two residents. Resident 52, who has severe cognitive impairment due to Huntington's disease, experienced multiple falls despite being identified as at high risk. The interventions in place, such as using a call light, were not suitable given the resident's cognitive limitations. The facility did not provide sufficient staff supervision or document effective interventions to prevent these falls, as evidenced by multiple incidents where the resident was found on the floor. Resident 49, who has moderate cognitive impairment and is dependent on staff for wheelchair mobility, fell in the dining room when attempting to sit back down in a wheelchair that rolled away. The staff failed to ensure the wheelchair locks were engaged, which directly contributed to the fall. The facility did not provide documented evidence that measures were taken to ensure the locks were engaged prior to the incident, compromising the resident's safety. Additionally, the facility failed to maintain a safe environment in a third-floor shower room, where a resident reported being burned by fluctuating water temperatures. The maintenance director acknowledged an issue with the facility's boiler, and the water temperature was found to be inconsistent. Staff did not check water temperatures before resident showers, and there was no assessment to determine if residents could safely shower independently. This oversight led to a resident experiencing discomfort and potential harm during a shower.
Plan Of Correction
1. R-52, R-49, R-78 & R-48 still reside in the facility. R-41 discharged to another SNF. 2. IDT Team met for R-52 and her individual care plan has been updated for safety interventions. R-49 is able to unlock his breaks independently; Fall(s) attributed to the acute onset and surgical intervention of Acute Appendicitis, Anti-rollback mechanism added to wheelchair. R-78 & R-48 are not independent in the shower room for showers. After residents were assessed by therapy, no resident was deemed to be an independent shower. 3. Fall prevention & safety education provided to staff. Facility will audit the last two weeks of residents falls to ensure appropriate interventions are in place. Outside plumber identified an issue with the main mixing valve on the water heater and replaced. Staff educated on taking water temperatures prior to showering of residents. 4. CNA/Nursing staff will complete purposeful rounding and complete tool five days/week for four weeks, then weekly for two months. Audit of shower temps to be completed three times per week for four weeks and weekly for two months. DON/designee will round three times per week for four weeks with audits submitted to the QA Committee for three months.