Failure to Eliminate Accident Hazards and Ensure Fall Prevention Measures
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. For one resident with diagnoses including metabolic encephalopathy, dementia, and fluctuating decision-making capacity, a long, looped cable was exposed above the head of the bed and within reach. This resident was observed repeatedly reaching for the cord, which was not secured in the wall-mounted cord protector. Both the Social Services Director and Maintenance Supervisor acknowledged the hazard, noting the resident's confusion and the potential for harm. The resident's care plan specifically called for a clutter-free environment, but this was not maintained. For another resident with muscle weakness, abnormal posture, and a history of lumbar fracture, the facility failed to follow physician orders to place landing pads on both sides of the bed. The resident had previously fallen while reaching for an item and was hospitalized. Despite orders and care plan interventions to reduce fall risk, observations showed that the landing pads were not positioned as required, with one pad against the wall and another in front of an unoccupied bed, both away from the resident. The Assistant Director of Nursing and Director of Nursing confirmed that the pads were not in place as ordered and that staff failed to monitor their placement as required by the physician's order. Both deficiencies were identified through observation, interview, and record review, and were inconsistent with the facility's policies on resident safety and fall management, which require maintaining a safe environment and implementing interventions to reduce fall risk.