Failure to Prevent Accidents and Ensure Safe Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for several residents, resulting in multiple deficiencies. One resident with a physician order and care plan specifying 'no straws' due to dysphagia was repeatedly observed with straws in their possession and using them to drink, despite clear documentation and staff awareness of the restriction. Staff interviews confirmed knowledge of the restriction, but straws continued to appear in the resident's room, and staff did not consistently remove them or prevent their use. Another resident was exposed to an accident hazard when a used needle and vacutainer from a blood draw were disposed of in the regular trash can in their room, rather than in a designated sharps container as required by facility policy. The nurse responsible admitted to discarding the needle improperly due to being rushed, acknowledging the risk of needle stick injuries and potential transmission of bloodborne pathogens. Housekeeping and infection control staff also recognized the improper disposal as a significant safety concern. A third resident sustained superficial burns after independently removing hot food from a microwave, an activity not addressed in their care plan despite their history of attempting to use staff microwaves. Staff statements revealed that residents were not permitted to use the staff breakroom microwave, but this resident had a pattern of accessing it, especially when new staff were present. The incident occurred when the resident was allowed to remove their food from the microwave without supervision, resulting in burns to their thigh and abdomen. The care plan did not address the resident's repeated attempts to use the microwave independently.