Penalty
Summary
The facility failed to provide a safe environment for residents, as evidenced by the lack of adherence to fall precautions for two residents and unsafe conditions in one of the nursing units. Resident R41, who has a history of seizure disorder and stroke, was observed in bed with only one floor mat on the right side, despite a physician's order for mats on both sides. Similarly, Resident R63, diagnosed with Alzheimer's disease and a seizure disorder, was found asleep in bed without the required floor mats, which were instead folded against the wall. Both residents were identified as being at risk for falls, yet the necessary precautions were not in place. Additionally, the facility's environment posed several hazards. An open container of bleach was accessible to residents near the Unit A/E nurses' station, and a baseboard heater in a resident's restroom was missing its cover, exposing sharp metal edges. Furthermore, the door to the
Plan Of Correction
1. The Director of Nursing/Designee will ensure that Resident R41 and R63 have fall mats properly placed on both sides of the bed as per their care plans. The Director of Nursing/Designee will conduct an immediate inspection to verify that all required fall mats are in place and properly positioned for all residents who have them included in their care plans. 2. The gallon-sized bleach container is removed from any resident-accessible areas and ensure the Nursing Home Administrator/Designee will ensure that all hazardous materials are securely stored in compliance with facility policies and safety regulations. 3. The Nursing Home Administrator/Designee will ensure repair of the exposed wiring and cover the baseboard heater in Resident R30's area to eliminate any risk of injury or accident. 4. The Nursing Home Administrator, Director of Nursing or Designee will conduct training sessions for all nursing and maintenance staff on the facility's safety protocols, focusing on the proper use and storage of fall prevention equipment and hazardous materials. 5. The Nursing Home Administrator, Director of Nursing or Designee will audit fall mats, heater covers, and loose wires on four units weekly times two then monthly times two. Updates on the progress of the implemented changes and invite feedback to improve safety measures during the Quality Assurance Performance Improvement meetings.