Failure to Prevent Accident Hazards and Ensure Safe Environment for Residents at Fall Risk
Penalty
Summary
Surveyors identified deficiencies related to accident hazards and inadequate supervision for residents at risk of falls. One resident with Huntington's disease, who was at high risk for falls and had a recent history of falling, was repeatedly observed in a Geri chair with unlocked wheels in busy areas of the facility. Despite the resident's involuntary movements and documented fall risk, the Geri chair was not consistently secured, and there were no specific care plan interventions addressing the safe use and placement of the Geri chair for this resident. The resident experienced multiple falls requiring hospital transfers during the survey period. In a separate incident, another resident identified as a fall risk had an IV pole stored on top of their safety fall mat in their room. This obstruction was observed on multiple occasions during the survey, despite the resident's documented history of falling. Staff interviews confirmed that safety rounds were intended to ensure fall mats were clear of objects, but the IV pole remained on the mat until it was pointed out by surveyors and subsequently removed by staff.