Failure to Maintain Safe Resident Environment and Prevent Accident Hazards
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for seven of nine sampled residents. In several instances, beds for residents at high risk for falls were not kept in the low position as required by their care plans and facility policy. For example, one resident with schizoaffective disorder, diabetes, and impaired mobility was found with their bed in a high position, despite being identified as a high fall risk and having a care plan intervention to keep the bed low. Staff interviews confirmed that the bed could have been lowered and that all staff are responsible for ensuring beds are kept at an appropriate height for safety. Multiple residents were found with bed remote control cords that had exposed or frayed wires. In several cases, staff observed and confirmed the presence of exposed wires on bed controllers, which were not reported or replaced in a timely manner. Facility policy and manufacturer guidelines both indicate that damaged cords should not be used, and staff interviews acknowledged the risk of electrocution from such hazards. Additionally, one resident's bed alarm was found turned off and not functioning, despite a physician's order and care plan requiring the alarm to be monitored and operational every shift. Staff confirmed the alarm should have been on to alert staff and prevent falls. Another resident's fall mat was found with furniture and medical equipment placed on top, creating dents and reducing the mat's effectiveness in preventing injury. Staff interviews confirmed that nothing should be placed on fall mats, as this compromises their function and could lead to injury if a resident falls. Facility policies reviewed consistently emphasized the need for a safe, hazard-free environment and regular checks to identify and mitigate risks, but these were not followed in the observed cases.