Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. For two residents with seizure disorders and severely impaired cognitive skills, the facility did not ensure that bed siderails were fully covered with padding as ordered by their physicians and outlined in their care plans. Observations revealed that one resident's bed rail padding had slipped, leaving hard rails exposed, and another resident's bed rail had no padding on one side. In both cases, nursing staff confirmed that the padding was necessary to protect the residents from injury during seizures, in accordance with physician orders and care plans. Additionally, the facility did not provide a required floor mat for a resident with impaired mobility and multiple medical conditions, including respiratory failure and cancer. This resident was found on the floor without a floor mat in place, despite a physician order and care plan intervention indicating its necessity for injury prevention. The resident's bed was positioned against the wall, and the room had low lighting with curtains drawn, making it difficult to see the resident from the hallway. Nursing staff acknowledged that the floor mat should have been present and that the room should have been better lit with curtains open for visibility. The facility's own policies and procedures require the prevention or reduction of hazards associated with bed rails, the provision of a safe and homelike environment, and adequate lighting to promote safety. The failure to follow these policies, physician orders, and care plan interventions resulted in an environment that placed the affected residents at increased risk for injury.