Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. One resident, who had multiple diagnoses including multiple sclerosis, COPD, acute kidney failure, and a seizure disorder, was observed to have two vape devices with cannabis symbols on her bedside table on multiple occasions. The resident reported using the vapes weekly in her room and keeping them on her bedside table. Facility staff, including an LVN and the Staff Development Assistant, acknowledged that they had not noticed the vapes during their daily rounds and recognized the potential risks, including negative exposure to other residents, possible contraindications with medications, and the risk of burns or injury to the resident herself. The facility's policy indicated that vape devices, while not considered smoking devices for ignition risk, still posed health and safety risks, including the potential for explosion or fire due to the battery. Another resident, with diagnoses including seizures, encephalopathy, and dysarthria, was found to have a left bed rail pad that was hanging off the bed rail during multiple observations. This resident was dependent on staff for most activities of daily living and was at risk for pressure ulcers and had a seizure disorder. Physician orders specified that the resident should have a low bed with padded bilateral upper half side rails and a floor mat to decrease potential injury. Both an LVN and the Assistant Director of Nursing confirmed that the left bed rail was not fully padded as required, and facility policy emphasized the importance of padding side rails for residents with seizure disorders to prevent injury during seizure activity. A third resident, with diagnoses including COPD, hypertension, type 2 diabetes, and muscle weakness, was found to have a personal lighter at his bedside, despite being a supervised smoker. The resident stated he was able to keep his lighter in his room, and an LVN confirmed that supervised smokers were not allowed to have lighters in their rooms due to the risk of burns or fire. Facility policy specified that residents without independent smoking privileges may not keep any smoking items, including lighters, except under direct supervision.