Failure to Secure Smoking Materials, Maintain Safe Water Temperatures, and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure that smoking materials were secured when not in use for two residents who were identified as independent smokers. Both residents were found in possession of cigarettes and lighters, contrary to facility policy which requires staff to store smoking materials in a secured area and only provide them to residents upon request. Staff interviews confirmed that even independent smokers were not permitted to keep smoking materials in their possession, and both residents had to be reminded and have their materials confiscated. Additionally, the facility did not maintain safe water temperatures in resident areas. During an environmental tour, water temperatures in two residents' rooms were measured at 130 degrees Fahrenheit, which was verified as too hot by the Director of Plant Maintenance. Review of facility logs showed inconsistent documentation of weekly water temperature checks, with several weeks missing. Staff and residents reported that the water was very hot, requiring the addition of cold water to prevent burns. The facility also failed to implement and document fall prevention interventions for a resident with a history of falls and significant cognitive and physical impairments. After an unwitnessed fall, the care plan called for hourly checks during the night, but there was no documented evidence that these checks were completed. The DON confirmed that the required checks should have been performed but were not documented.