Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision to prevent accidents for three residents. In one instance, a resident's bathroom sink water temperature was measured at 121.3°F, exceeding the facility's stated safe range of 110°F to less than 120°F. The resident, who was cognitively intact and had multiple medical diagnoses, reported that the water felt very hot but had not experienced any injury. The maintenance director confirmed the temperature was above the required limit and acknowledged the need for seasonal adjustments to maintain safe water temperatures. Documentation showed that previous checks in the same room had recorded temperatures within the acceptable range. In another case, staff failed to follow the required transfer protocol for a resident with severe cognitive impairment and significant physical limitations. The resident's care plan and Kardex specified that all transfers should be performed using a Hoyer lift with two staff members. However, observations revealed that staff transferred the resident manually, without the lift, and at one point, a single staff member completed the transfer alone after another was unable to assist. Both CNAs involved stated they had never used the Hoyer lift for this resident, despite the care plan instructions. The DON confirmed that the care plan and Kardex should accurately reflect the required transfer method and that not following it could result in injury. Additionally, the facility failed to complete a required assessment and obtain a physician's order before applying a wander guard device to a resident at risk for elopement. The resident, who had severe cognitive impairment and a history of wandering, was observed wearing a wander guard without a current elopement risk assessment or a physician's order documented in the medical record. The DON acknowledged that both an assessment and a physician's order were required for the use of such a device, and facility policy supported this requirement.