Failure to Maintain Resident Environment Free of Accident Hazards
Penalty
Summary
A deficiency was identified when a resident's room was found to be cluttered with multiple boxes blocking the door from opening fully and a carpet with curled edges on the floor. The resident, who had a history of Type 2 Diabetes Mellitus and generalized muscle weakness, was observed lying in bed and later ambulating both with and without a walker. The room was described as disorganized, with scattered personal belongings and a strong smell of urine. The presence of the boxes and the curled carpet created obstacles and potential trip hazards within the resident's environment. Interviews with facility staff, including the Social Services Director, Licensed Vocational Nurse, Housekeeping Staff, Certified Nursing Assistant, and the Director of Nursing, confirmed awareness of the cluttered and hazardous state of the resident's room. Staff acknowledged that the room posed safety and health risks, including being a potential fire and fall risk. Despite this, the resident's care plan and interdisciplinary team documentation did not address the environmental hazards or include interventions to mitigate these risks. The facility's policy on falls and fall risk management requires staff to identify and implement interventions related to specific risks, including environmental factors such as obstacles in the footpath. However, the lack of documentation and action regarding the cluttered room and trip hazards indicated a failure to ensure the resident's environment was free from accident hazards and to provide adequate supervision to prevent accidents.