Failure to Maintain Safe Environment and Supervision on Memory Care Unit
Penalty
Summary
The facility failed to maintain an environment free from potential accident hazards on the Memory Care Unit. Observations revealed three electrical outlets in a hallway without covers, exposing wiring, and an unsecured activity room containing accessible hazardous materials such as wipes, food items, hand sanitizer packs, sugar packs, sharp metal file holders, tape, paperclips, binding clips, electrical extension cords, and a coiled wire. These items were accessible to residents, including one resident observed attempting to wheel through the hallway during the inspection. A registered nurse confirmed the presence of these hazards. Additionally, a resident with dementia, anxiety, insomnia, and kidney disease, who was admitted to the secured memory care unit, was found to have removed their elopement (wanderguard) bracelet using nail clippers. The nurse took the clippers and replaced the bracelet, but the incident was only documented on an incident statement form without a full investigation. The Nursing Home Administrator confirmed that no investigation was conducted, and the facility did not ensure an environment free from potential accident hazards.
Plan Of Correction
All items cited on the Willow unit were removed from the shelving/drawers and outlet covers were installed immediately. R225 did not sustain any injury due to removing their security bracelet with nail clippers. Nurse statement revealed family member admitted to bringing the clippers and they were immediately removed, warranting no further investigation. Rounds were completed in each room of the Willow unit to ensure no hazardous items were present. No further items were discovered. NHA or designee will educate memory care staff on maintaining a hazard-free environment. Unit Manager or designee will audit the unit for potential hazards twice weekly for 4 weeks, then monthly for 2 months. Results will be reviewed at QAPI and revised as needed.