Failure to Prevent Accident Hazards and Implement Fall Risk Interventions
Penalty
Summary
A deficiency was identified when a shower room was found to have accident hazards, including a broken shower head leaking water onto the floor and a clogged drain resulting in approximately two inches of cloudy water accumulating in one of the showers. Maintenance staff confirmed that these issues had not been reported prior to the surveyor's observation, and acknowledged that such hazards could lead to slips and falls. Facility policy required prompt reporting and repair of non-functioning equipment to maintain a safe environment, but this was not followed in this instance. Another deficiency involved the failure to implement and accurately complete fall risk assessments for residents after falls. In one case, a resident with a history of falls and cognitive impairment experienced a fall, but the post-fall risk assessment was incomplete, omitting critical information such as recent fall history, gait and balance status, and predisposing diseases. In a separate case, a resident's post-fall risk assessment was inaccurately completed, with the nurse failing to document the correct number of falls in the past three months, resulting in a lower risk score than appropriate. Facility policy required thorough and accurate completion of fall risk assessments to guide interventions, but this was not adhered to. Additional deficiencies were observed in the implementation of care plan interventions. One resident, identified as being at risk for falls, was found in bed with the bed in a high position, contrary to the care plan directive to keep the bed in the lowest position. Staff confirmed the bed should have been kept low to prevent injury. Another resident with a seizure disorder and a care plan intervention for padded siderails was observed in bed without the required padding. Nursing staff acknowledged that the absence of padded siderails did not align with the care plan and could result in injury during a seizure. These findings demonstrate failures to follow individualized care plans and facility policies designed to prevent accidents and injuries.