Resident Access to Hazardous Materials Due to Staff Oversight
Penalty
Summary
The facility failed to ensure that the resident environment was free of accident hazards, specifically by allowing a resident access to hazardous materials. Resident R575, who was admitted with a history of opioid dependence, homicidal ideations, and a previous suicide attempt, was observed holding two razors in the doorway of their room. The resident's care plan included interventions to prevent self-harm, such as removing harmful items from the room and maintaining hourly checks. The incident occurred when Employee E4, a nursing assistant, accidentally left the razors in the bathroom, making them accessible to the resident. Interviews with the Director of Nursing and other staff confirmed that the resident should not have had access to razors, given their history of behaviors and the existing care interventions. This oversight highlights a lapse in maintaining a safe environment for the resident, as required by the facility's policies.
Plan Of Correction
1. On 12/18/2024 the razors were immediately discarded by the CNA. There were no negative outcomes or injuries noted for Resident R575. 2. On 12/18/2024 the nursing staff checked resident rooms to verify that there were no razors left in the room and/or bathrooms. None were identified. 3. On 12/26/2024 the NHA educated the nursing staff on maintaining safety measures for residents regarding razors. 4. The DON/designee will conduct audits 2 times a week for 4 weeks and monthly for 3 months verifying that residents' rooms are free of razors. Results of the audits will be reviewed at the QAPI meeting held monthly.