Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for multiple residents. In several instances, medications were left unattended and accessible in residents' shared rooms, despite assessments indicating that these residents were not safe candidates for self-administration. For example, one resident had a cup containing multiple medications left on the bedside table by an LVN, who stated that the resident preferred to take medications one at a time. However, there was no physician's order or assessment supporting self-administration, and facility policy required direct observation during medication administration. Additionally, topical medications such as A&D ointment were left at the bedside and on the floor, and were applied by a CNA without a physician's order, contrary to facility policy and scope of practice requirements. Hazardous materials were also found in resident rooms without proper supervision. One resident had a large aerosol can of bug spray stored on a dresser next to food items. Staff who observed the spray did not remove it, despite facility policy prohibiting hazardous chemicals in resident rooms and the potential for confused or wandering residents to misuse such items. The Director of Nursing confirmed that the presence of bug spray in a resident's room was not in accordance with facility policy and posed a risk to residents. Environmental hazards were present in the form of improper use and maintenance of safety equipment. Several residents who were at risk for falls had floor mats intended to prevent injury, but these mats were obstructed by furniture or medical equipment, such as visitor chairs and overbed tables, which compromised their effectiveness. In one case, a resident's fall mat had a significant tear, and in others, beds were not maintained in the lowest position as required by care plans. Additionally, a resident was found using a heating pad without a physician's order, and another had a bed remote with frayed wires, both of which posed risks of injury or electrocution. These deficiencies were observed during interviews and record reviews, and staff acknowledged that such practices were not in line with facility policies and procedures.