Failure to Prevent Accidents and Maintain Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for multiple residents. For one resident with dementia and a high risk for falls, the care plan was not updated with new interventions following several falls, and neurological checks were not consistently completed as ordered after each incident. The care plan interventions were either delayed or not implemented, and documentation of post-fall assessments was incomplete or missing. Staff interviews confirmed that new interventions should have been added after each fall, but this was not consistently done, and communication of interventions to direct care staff was lacking. Another resident, who was dependent on a wheelchair and required maximal assistance, was allowed to leave the facility for non-medical reasons without a current physician's order for a leave of absence (LOA). The system for tracking residents on LOA was ineffective, with incomplete and illegible log entries, and staff were unable to confirm which residents were off the premises at any given time. Staff interviews revealed that verification of LOA orders was not consistently performed, and the facility could not account for residents in the event of an emergency due to the lack of an effective tracking system. Additionally, a resident with severe cognitive impairment and a physician's order requiring assistance for ambulation was observed ambulating independently without staff assistance or an assistive device. This was contrary to the care plan and physician's order, and the resident experienced multiple falls and injuries as a result. Furthermore, the facility failed to maintain an accident-free environment for several cognitively impaired residents by not monitoring hot water temperatures, resulting in water temperatures exceeding safe limits in multiple rooms. The facility had not conducted routine water temperature checks for several months, and the equipment used for monitoring was inappropriate, leading to inaccurate readings.