Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for several residents. One resident's fall mat was observed to be stuck under the wheel of the bed and protruding, creating an accident hazard. Additionally, the bathroom and shower room floors for four residents were found to have a buildup of a grey, greasy substance, making the floors excessively slippery. Multiple residents reported that the bathroom floors were very slippery when wet, and two residents stated they had fallen in the bathroom due to the slippery conditions. Staff interviews revealed that the maintenance director and administration were not aware of the slippery floors, and the maintenance director suggested improper cleaning practices could be the cause. In another incident, a resident with severe cognitive impairment, a history of repeated falls, and agitation was left unsupervised in a geri-chair while the assigned CNA left the room to retrieve supplies. The resident fell from the chair, resulting in a head laceration and requiring hospital evaluation. The CNA acknowledged that he should not have turned his back on the resident and should have gathered all necessary supplies beforehand. The DON confirmed that the resident was care planned for falls and that staff were expected to maintain supervision. The facility's policy required monthly environmental rounds to ensure a safe and functional environment, but observations and interviews indicated lapses in both environmental safety and staff supervision. The lack of awareness and failure to address known hazards, such as improperly placed fall mats and slippery bathroom floors, as well as inadequate supervision of high-risk residents, directly contributed to the deficiencies identified during the survey.