Failure to Prevent Accident Hazards and Ensure Use of Safety Devices
Penalty
Summary
Surveyors identified that the facility failed to ensure the resident environment was free from accident hazards and did not provide adequate assistance devices to prevent accidents. During observations, hand sanitizer bottles were found stored on top of EBP carts and in unlocked drawers, making them accessible to residents, including those with altered cognition. Staff and administration confirmed that this was the usual storage method, and there was no documentation of the hand sanitizer in the facility's MSDS book in case of ingestion. The facility relied on staff monitoring to prevent resident access to these hazardous substances, but no physical barriers or secure storage were in place. Additionally, a resident with severe cognitive impairment, muscle weakness, and a history of falls was observed multiple times in bed without fall mats present, despite a recent fall from bed that resulted in a facial injury and a hospital transfer. The care plan for this resident included interventions such as a lowered bed, call light within reach, and fall mats, but the fall mats were not in place during repeated observations. These failures were noted across all resident halls reviewed and placed residents at risk for injury due to inadequate supervision and lack of required safety devices.