Failure to Prevent Accidents and Investigate Falls
Penalty
Summary
The facility failed to identify and mitigate accident risks for two residents, resulting in harm and increased risk of injury. One resident, who was cognitively intact but required moderate to maximum assistance for activities of daily living following a recent pelvic fracture, suffered a third-degree burn to the left thigh when hot soup was served on an overbed table. The resident attempted to pull the tray closer, causing the soup to spill onto their lap. The soup had been held at a temperature of 187 degrees Fahrenheit in the kitchen, and there was no process in place to ensure the temperature was safe for direct consumption or handling by residents. The facility did not assess the resident's ability to safely handle hot liquids after the incident, nor did they have protocols to check the temperature of microwaved food before serving. Additionally, the facility failed to provide consistent supervision and thorough investigation following multiple falls experienced by another resident with dementia, degenerative joint disease, and moderately impaired cognition. This resident had nine falls over five months, with only two of the incidents resulting in updated interventions to reduce fall risk. For the seven unobserved falls, there were no witness statements or thorough investigations to determine the cause or to rule out abuse or neglect. The care plan for this resident identified multiple risk factors for falls, but interventions were not consistently updated after each incident. Interviews with facility staff, including the Administrator, Director of Nursing, and Regional Clinical Director, confirmed that no follow-up assessments or comprehensive investigations were conducted after the incidents. The lack of individualized assessment for handling hot liquids and insufficient investigation and intervention following repeated falls contributed to ongoing risks for the residents involved.