Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision for three of five sampled residents, resulting in multiple deficiencies. For one resident with osteoarthritis and psychosis, staff did not ensure the call light was within reach or that the resident was wearing non-slip footwear, as required by the fall risk care plan. Observations showed the call light was disconnected and placed out of reach, and the resident was seen getting out of bed without assistance and with bare feet, despite being at risk for falls. Staff interviews confirmed awareness that the call light should have been accessible and that the resident required supervision and appropriate footwear to minimize fall risk. Another resident with schizophrenia and bipolar disorder experienced an unwitnessed fall, but the facility did not conduct an Interdisciplinary Team (IDT) meeting within 24 hours as required by facility policy. The resident was found on the floor with minor injuries after attempting to use the restroom while not fully awake. The Director of Nursing acknowledged that the IDT meeting, which is intended to review the incident and develop preventative interventions, did not occur, leaving the resident at risk for repeat falls. A third resident with diabetes, congestive heart failure, and dysphagia was observed taking and consuming food from another resident's tray on a food cart in the hallway. This resident was on a mechanical soft diet due to swallowing difficulties and was at risk for aspiration. Staff confirmed that the resident's care plan required monitoring during meals and that eating from another tray posed a choking and infection risk. The food cart was accessible, and staff acknowledged that it should have been secured to prevent residents from accessing inappropriate food.