Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
A deficiency was identified when a razor blade was found on the floor in the room of a resident with severe cognitive impairment and significant physical limitations. The resident required partial or moderate assistance with eating and hygiene, and was fully dependent for toileting, dressing, repositioning, and transfers. The razor blade was observed by staff during a room check, and it was confirmed that razor blades are not permitted in resident rooms due to the risk of injury. Staff interviews indicated that the razor blade was likely left behind by a CNA after assisting the resident with shaving, and both the Infection Preventionist Nurse and Registered Nurse Supervisor acknowledged that this was a violation of facility policy and posed a hazard to the resident and staff. Another deficiency was observed when medication was left unattended on the bedside table of a resident with moderate cognitive impairment and multiple medical conditions, including diabetes, end stage renal disease, and dysphagia. The medication, identified as Tums, was left by a nurse for the resident to take at their convenience. Staff interviews confirmed that medication should not be left at the bedside, regardless of whether it is over-the-counter, as it could be accessed by the resident or others, potentially leading to harm. The nurse responsible acknowledged the error and stated that it was a mistake not to check the room during rounds. Facility policy review indicated that environmental hazards include unattended equipment and sharp objects accessible to vulnerable residents. Both incidents involved a failure to maintain an environment free from accident hazards, as required by facility policy, and were confirmed through staff interviews and direct observation.