Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for several residents. During an observation of a resident's room, it was found that the closet/storage cabinet was unsecured. The Maintenance Director confirmed that all 103 resident rooms in the facility had unsecured closet/storage cabinets due to ongoing refurbishment, and that new secured cabinets had been ordered but were not yet installed. This left all resident rooms with unsecured storage, which could pose a risk of tipping and injury, especially during events such as earthquakes. In another instance, a resident with moderate cognitive impairment was observed with a pair of long scissors on their overbed table. Interviews with nursing staff confirmed that the resident was not permitted to have scissors at the bedside, and staff were unsure how the resident obtained them. The resident was noted to be independent and ambulatory within the facility. The facility's policy allowed residents to retain personal possessions unless it posed a health or safety risk, but the presence of scissors at the bedside was not permitted for any resident. Additionally, a resident receiving oxygen therapy was found to have a portable oxygen cylinder in their room without the required signage indicating oxygen use. Facility policy required a "No Smoking" sign on the room entrance and an "Oxygen in Use" sign over the resident's bed when oxygen therapy was being administered. Observations and interviews with nursing staff confirmed that the necessary signage was not posted in the resident's room, despite an active physician's order for oxygen therapy.