Failure to Prevent Accident Hazards and Ensure Resident Supervision
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for multiple residents, as evidenced by several observed deficiencies. One resident on swallow precautions, with a history of stroke and recurrent pneumonia, was left unsupervised while eating breakfast and was not positioned at the required 90-degree angle. The assigned staff member admitted to leaving the resident alone during meals, despite clear orders and posted signage requiring supervision and specific positioning to prevent aspiration or choking. Another resident with cognitive deficits and a diabetic foot ulcer had a bottle of Daikin's solution, a strong antiseptic, left at the bedside mixed with food items. Facility staff acknowledged that medications should not be left at the bedside due to the risk of accidental ingestion. Additionally, a resident with severe cognitive impairment and high fall risk was found to have a call light cord with exposed/frayed wires and fall mats with furniture and equipment placed on top, compromising both electrical safety and the effectiveness of the fall mats. Similar issues were observed with another resident, where overbed tables were placed on top of bilateral floor mats, increasing the risk of injury and reducing the protective function of the mats. A further deficiency was noted when a resident with dementia and impaired safety judgment had an unattended medication cup containing ointment left at the bedside, accessible for self-administration. Multiple staff members entered the room without removing the ointment, and it remained on the nightstand for an extended period. Staff interviews confirmed that medications should not be left unattended in resident rooms, especially in units where residents have dementia and impaired safety awareness. Facility policies and procedures reviewed during the survey supported the need for a hazard-free environment and proper medication administration practices, which were not followed in these instances.