Failure to Prevent Accidents and Ensure Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that residents identified as being at risk for falls were adequately protected from accidents and injuries. For one resident with a history of dementia, osteoporosis, repeated falls, and impaired cognitive skills, the care plan included the use of a talking device (bed alarm) to remind and redirect the resident to call for assistance. However, the device was found to be disconnected at the time of a fall that resulted in multiple fractures and hospitalization. Staff interviews and documentation revealed that the resident was able to manipulate or turn off the device, and the care plan was not revised after previous falls to implement new interventions, despite evidence that existing measures were ineffective. Another resident, who required supervision at all times due to fall risk and a history of repeated falls, was left unsupervised in the designated smoking area. The care plan and facility policy required direct supervision while smoking, but the assigned staff member left the resident alone after initially supervising for a short period. The resident subsequently fell from the wheelchair while attempting to pick up a dropped cigarette, sustaining a nasal fracture, facial abrasions, and swelling, and required transfer to an acute care hospital for evaluation and treatment. Staff interviews confirmed that there was no consistent assignment for smoking supervision, and the responsible staff acknowledged the failure to provide required supervision. Additionally, the facility failed to ensure that a spray bottle containing isopropyl alcohol on a medication cart was properly labeled. The bottle, used for hand sanitizing, was transferred from a larger container but left unlabeled, creating a potential risk for accidental exposure or ingestion by residents. Both the DON and QA LVN acknowledged the importance of labeling such containers to maintain safety and prevent accidental ingestion.