Failure to Prevent Accident Hazards and Ensure Supervision
Penalty
Summary
A resident was found to be at risk for accidents due to multiple lapses in safety and supervision. On two separate occasions, the resident's call light was not within reach—once entangled in linens and another time on the floor—leaving the resident unable to summon assistance when feeling unwell. Additionally, the resident's bed was observed at its highest position, and the resident was unable to lower it independently. Staff acknowledged that the call light should always be accessible and that the resident required a Geri chair due to issues with the wheelchair armrests and risk of sliding out. Potentially hazardous products, including hydrogen peroxide and Comet household cleaner, were found at the resident's bedside. Staff indicated these items were likely left by the resident's family, who frequently brought in various items without notifying staff. There was no documentation of staff educating the family about safety or addressing the issue, and the unit manager was unaware of the situation. The resident had significant medical conditions, including impaired cognitive function, incontinence, and required assistance with activities of daily living.