Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
A licensed nurse left 11 oral medications at the bedside of a resident who had been assessed as not safe to self-administer oral medications. The resident, who had impaired cognitive skills and required assistance with activities of daily living, was observed with the medications and a cup of applesauce, some of which had been crushed and mixed in. The nurse admitted to leaving the medications unattended after being distracted by another staff member, and the Director of Nursing confirmed that the resident was only assessed as safe to self-administer inhalers and eyedrops, not oral medications. Facility policy required that medications be administered within 60 minutes of the scheduled time and that residents be observed to ensure ingestion, which was not followed in this instance. Another deficiency involved a resident with a history of epileptic seizures who did not have bed rail padding in place as ordered by the physician. The resident's bed rails were observed to be metal and unpadded, and the Assistant Director of Nursing acknowledged that the required padding was not present. The facility's policy indicated that padded side rails may be used for residents with a seizure history to provide protection, but this was not implemented for the resident in question. A third deficiency was identified when a resident at high risk for falls, with diagnoses including anoxic brain damage and seizures, did not have landing mats at the bedside as ordered by the physician and outlined in the care plan. The resident was assessed as being at high risk for falls, and the order for a low bed with landing mats was not followed. The Director of Nursing confirmed the absence of landing mats and stated their importance in preventing or lessening injuries from falls. Facility policy required adequate supervision and assistive devices to minimize fall risks, which was not adhered to in this case.