Failure to Address Environmental Hazards and Secure Medications
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two of five residents reviewed for accident hazards. In one instance, a resident with a history of falls and multiple medical conditions, including spinal stenosis and chronic pain, reported that the grab bar in his bathroom was loose and that an additional grab bar recommended by the occupational therapist (OT) had not been installed. Despite a work order being submitted and marked as completed, the grab bar remained unrepaired and the additional bar was not installed. The resident expressed fear of using the bathroom due to the loose grab bar and stated that the lack of proper grab bars contributed to a fall incident. Staff interviews confirmed that the maintenance department did not routinely check grab bars and that there was a lack of communication and follow-up regarding the work order. In another case, a resident with severe cognitive impairment and total dependence on staff for activities of daily living was found to have a bottle of Dakin's solution, a topical antiseptic, left unsecured on his bedside table. The solution was used for wound care, and nursing staff stated it was left in the room to avoid contamination. However, facility policy required all medications and treatments to be stored securely and not left in resident rooms. The unsecured Dakin's solution was observed during a room check, and staff confirmed it should not have been left accessible to the resident. Both deficiencies were identified through observations, record reviews, and staff and resident interviews. The facility's failure to repair and install necessary safety equipment and to properly secure medications and treatments directly contradicted its own policies and procedures, as well as recommendations from clinical staff. These lapses resulted in an environment that was not free from accident hazards and did not provide adequate supervision to prevent accidents for the residents involved.