Failure to Implement Required Safety Interventions for Two Residents
Penalty
Summary
The facility failed to provide a safe and hazard-free environment for two residents by not implementing required safety interventions as outlined in their care plans and physician orders. For one resident with diagnoses including respiratory failure, chronic kidney disease, and unspecified dementia, the care plan and physician order required the use of a bed pad alarm to alert staff if the resident attempted to get out of bed unassisted. Despite being identified as high risk for falls, the resident was observed in bed without a pad alarm and attempting to get up. Interviews with nursing staff and the Director of Nursing confirmed that the bed alarm was not in place, and the physician order and care plan were not followed. Another resident, diagnosed with epilepsy, hypertension, and pneumonia, was at risk of injury during seizures. The care plan required sheep skin padding on both side rails to prevent injury during seizure activity and mandated that staff confirm placement every shift. Observations revealed that the resident's side rails were not padded, and interviews with nursing staff and the Director of Nursing confirmed that the intervention was not implemented as required by the care plan. Review of facility policies indicated that physician orders and individualized care plans are to be followed to ensure resident safety and minimize risks such as falls and injuries. In both cases, the required interventions were not in place at the time of observation, and staff acknowledged that the care plans and physician orders were not followed, resulting in an unsafe environment for the residents involved.