Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
Staff failed to ensure a safe environment free from accident hazards for all residents by not following facility policies regarding smoking supervision, storage of hazardous items, and staff personal belongings. Specifically, there was conflicting documentation in a resident's smoking assessments regarding the need for supervision, despite the resident having dementia. The Director of Nursing confirmed that residents with dementia were expected to be supervised while smoking, but the assessments were inconsistent. Additionally, observations revealed that lighters were found in multiple resident rooms, contrary to facility policy requiring all smoking supplies to be stored by staff at the nurses' station. Staff interviews confirmed that lighters were sometimes left with residents, and staff were not always successful in retrieving them. Further deficiencies included staff storing personal belongings such as purses and bags in resident rooms, which was against facility expectations and posed potential hazards. Observations also found unsecured bleach cleaning wipes left in a resident bathroom, with the container open and accessible. Staff interviews indicated a lack of awareness regarding the hazards of leaving such items accessible to residents. These actions and inactions placed residents at risk for burns, fire-related injuries, chemical exposure, and ingestion of unsafe substances.