Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and provide adequate supervision to prevent accidents for several residents. For one resident, two tubes of triamcinolone acetonide cream were left unattended at the bedside, despite the resident not having an order for the medication and not being evaluated for self-administration. This oversight was observed by multiple staff members, including a CNA and an LVN, who acknowledged the error but did not take immediate action to rectify it. The presence of the cream posed a risk of self-administration and potential adverse reactions. Another resident, who was at high risk for falls, had a floor alarm that was not activated, leaving the resident unattended and vulnerable to falls. The RN responsible for the resident admitted to turning off the alarm and leaving the resident without supervision, which was against the facility's policy. This lapse in supervision could have resulted in a fall and subsequent injury to the resident. Additionally, the facility failed to ensure that fall mats were free from obstructions for several residents. Observations revealed that furniture and medical equipment were placed on top of fall mats, increasing the risk of injury if a resident were to fall. Furthermore, the facility did not complete post-fall monitoring for a resident as per policy, missing several shifts of documentation and monitoring after a fall incident. These deficiencies highlight a lack of adherence to safety protocols and procedures designed to protect residents from avoidable accidents.
Plan Of Correction
B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents with the use of pad alarms, landing mats, and medications left unattended at the bedside are potentially affected by the facility practice. The Director of Nursing/designee audited the rooms of residents who use alarms and landing mats to ensure alarms were turned to the on position when the resident is using the device and to ensure furniture or other items are not obstructing the landing strip on 2/27/2025. Five other patients were affected, and the furniture was moved so that it was not obstructing the mat on 2/27/2025. The Charge Nurse audited all resident rooms to identify residents with unattended medications at the bedside on 2/24/2025. No other affected residents were found. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Staff Development will re-educate the nursing staff on 3/18/25 the facility policy and procedure, "Accidents and Fall Management," with emphasis on the requirements to: 1. Medications should not be left at the bedside in the absence of residents assessed and approved for self-administration of medications. 2. Floor pad alarms should be in the on position when the resident is in bed. 3. Liquids on the floor are everyone's responsibility and should be cleaned by the appropriate personnel when seen, and a wet floor sign should be placed over the wet area. 4. Furniture should be clear of fall mats to reduce the potential for the furniture to obstruct a resident's fall. 5. Post-fall assessments should be completed following each episode of falling for residents. The Director of Staff Development will orient new nursing personnel, at the time of hire and annually, on the facility policy and procedure, "Accident Management," with emphasis on resident monitoring, activating alarms, not leaving medications at bedside, and attending to spills on the floor for safety. The Registered Nurse Supervisors will complete walking rounds during their assigned shifts at the beginning of their shifts to ensure resident interventions to reduce falls and/or reduce injury with falling are implemented, including ensuring alarms are activated and that furniture or other obstructions are not blocking the mats. They will also identify if residents have medications at their bedside. The Administrator revised the Management Team's rounding tool to include identification of medications at the bedside and unsafe hazards, including fluid on the floor, alarms not activated, landing strips with obstructions, and medications at the bedside. Management team consists of all department heads with room rounds. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Management Team will monitor their assigned resident rooms five times weekly to ensure compliance with medications, landing mats, alarms, and fluid spills for the safety of all residents. The DSD will complete safety rounds daily during routinely scheduled work hours to ensure resident safety interventions are implemented, including proper functionality of pad alarms, placement of landing mats, and no spills on the floors. Concerns identified will be corrected at the time of observation and reported to the Director of Nursing. The Director of Nursing will monitor the licensed nurses and certified nursing assistants' performance through direct observation, Department Manager audits, and DSD rounds; and provide re-education or progressive disciplinary action as indicated. The Director of Medical Records/Designee will audit nurses' follow-up charting daily after a fall. The Administrator will conduct routine rounds each day during routinely scheduled work hours to ensure residents are supervised and safety interventions are activated, without obstructions, and floor signs are placed where spills have been cleaned. The DON/designee will report trends identified in resident care plans, assessment, supervision, and safety intervention observations and audits to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025. F 689 F 689 F 689 F 689 F 690 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 83's catheter drainage bag was adjusted to ensure the drainage tube did not have a kink or a loop to reduce the potential for development of urinary tract infection on 2/26/2025. Resident 53's catheter drainage bag was adjusted to ensure the drainage tube did not have a kink or loop to reduce the potential for development of urinary tract infection on 2/26/2025. The DON audited Resident 83 and Resident 53's changes in condition from 2/1/2025 through 2/26/2025 to identify if either resident developed a urinary tract infection. Neither resident experienced a UTI in the month of February.