Failure to Prevent Accident Hazards and Enforce Smoking and Supervision Policies
Penalty
Summary
Staff failed to follow physician orders and professional standards of practice for safe resident transfers and supervision, resulting in multiple deficiencies. In one instance, a resident with hemiplegia and muscle weakness, who was dependent on staff for transfers, was moved using a sit-to-stand mechanical lift by a single nursing assistant instead of the required two staff members. During this unsupervised transfer, a lift strap detached, though the resident did not fall. Facility documentation and interviews confirmed that the resident was supposed to be transferred with two staff, as per care plan and manufacturer guidelines, but this was not followed. Several residents with a history of smoking or current smoking behavior were not adequately supervised or prevented from smoking on facility grounds, contrary to the facility's non-smoking policy. Residents were found in possession of cigarettes and lighters, and some were observed smoking in designated outdoor areas without staff supervision or fire safety measures in place. Interviews revealed that staff were aware of these behaviors but did not consistently intervene or conduct searches for smoking materials after violations. Residents and visitors were able to bring in and use smoking materials, and there was a lack of clear communication and enforcement of the non-smoking policy. Additionally, a resident at high risk for aspiration due to severe dysphagia was left unattended with a meal tray and accessible fluids at the bedside, despite orders and care plans requiring total assistance and supervision during feeding. Observations showed that the resident was unable to feed themselves or safely access food and drink, yet staff left food and thickened liquids within reach, increasing the risk of aspiration. Another resident with dementia and a high fall risk was left alone in the bathroom by a nursing assistant, resulting in an unwitnessed fall and subsequent injury. Staff interviews indicated a lack of awareness and education regarding which residents required continuous supervision during toileting.