Failure to Develop and Implement Care Plan Interventions for Resident Safety
Penalty
Summary
The facility failed to develop and implement care plan interventions to monitor and prevent accidents for a resident, resulting in a potentially unsafe environment. During observations, the resident's call light was found on the floor and out of reach, and the resident was unaware of its location while expressing feeling unwell and requesting assistance. The bed was positioned at its highest height, further increasing the risk of accident. Staff acknowledged that the call light was out of reach after care had been provided, and it was noted that someone had just left the room without ensuring the call light was accessible. Additionally, hazardous items such as hydrogen peroxide and comet cleaner were found on the resident's bedside table on separate occasions. Staff indicated that the resident's family frequently brought in items and left them without informing staff, and there was no documentation of interventions, education, or care planning to address this ongoing behavior. The care plan did not include any measures to address the family's actions or to prevent unsafe items from being left with the resident, despite the resident's medical history of rheumatoid arthritis, dysphagia, lower back pain, diabetes mellitus with neuropathy, hypertension, acute kidney failure, and spinal stenosis.