Inadequate Supervision and Smoking Policy Deficiencies
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate interventions for a cognitively impaired resident at high risk for falls, resulting in multiple falls with injuries. Resident #39, who had a severe cognitive impairment and a history of falls, was observed without proper supervision and necessary safety measures, such as leg rests on their wheelchair. Despite being identified as a high fall risk, the resident experienced numerous falls over several months, with injuries including skin tears, bruises, and head trauma. The facility's fall risk management policy was not effectively implemented, as interventions were not consistently reassessed or revised following each fall. The facility also failed to develop and implement a consistent smoking process to prevent potential injury or fire for residents who smoked. Five residents were identified as being affected by this deficiency. The facility lacked a clear smoking policy, and staff were not adequately informed about the smoking process, including the supervision of residents while smoking and the secure storage of cigarettes and lighters. Observations revealed that residents had access to cigarettes and lighters, and there was no consistent use of protective devices, such as smoking aprons, for residents who required them. Interviews with staff and residents highlighted a lack of awareness and understanding of the smoking procedures, with some staff unable to provide information on where smoking supplies were kept or which residents required additional safety measures. The facility's failure to conduct thorough investigations and root cause analyses for falls, as well as the absence of a comprehensive smoking policy, contributed to the deficiencies identified by the surveyors.
Plan Of Correction
Survey Completion Date: 12/12/24 F689 SS - E (Free of Accident Hazards/Supervision/Devices) Element One: The facility's practice is to ensure that the resident's environment remains as free of accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents. An audit was completed immediately on all residents within the last month to ensure an intervention was in place and on the care plan. Education provided to staff to ensure a thorough investigation is conducted when a fall occurs. It is the practice of the facility to implement a smoking process to ensure the safety of residents to prevent injury or fire. Education provided immediately for the residents and staff on the smoking policy and process. Element Two: This standard was not met for Resident #39, #11, #33, #54, #63, and #388. All residents who have had an accident and/or smoke have the potential to be affected by this deficient practice. Element Three: The Administrator/Designee, DON/Designee, and Unit Managers/Designee met to review the incident and accident report procedure. All incident and accident reports will be reviewed with the Interdisciplinary team within 72 hours post fall/accident to ensure immediate interventions that were implemented are addressed and updated on the care plan, as well as any additional interventions needed. In addition, 6 residents with a PMH of multiple falls and poor cognition have been identified as a focus group to help decrease falls and injury with specialized diversional activities and groups. The Administrator met with residents and staff regarding the smoking process and implementation of a smoking binder. The residents were explained the importance of smoking safety and following the rules. They were educated about not holding their cigarettes and lighters as well as the designated smoking times. The residents were also educated on the facility's safety procedures regarding smoking. Element Four: An audit of two charts will be conducted weekly by the DON/Designee for three months to ensure residents with fall(s) have appropriate interventions in place and interventions are on the care plan. Results are to be reported to the QAPI team for review. The Administrator/Designee will complete observation of the smoking process monthly x 3 to ensure compliance. Date of compliance: 12/25/2024