Failure to Prevent Accidents and Ensure Safe Smoking Environment
Penalty
Summary
The facility failed to implement appropriate interventions and provide adequate supervision to prevent accidents and injuries for multiple residents. One resident with severe cognitive impairment, a history of falls, and a recent diagnosis of dementia and agitation was found on the floor with a skull fracture after attempting to get out of bed unassisted. The resident's care plan included reminders to request assistance and keeping the call light within reach, but interviews with staff and the psychiatric nurse practitioner revealed that the resident was unable to use the call light due to confusion and severe cognitive deficits. Despite these known limitations, no additional supervision or interventions were implemented prior to the fall, and the psychiatric nurse practitioner was not notified of the incident, which would have required a follow-up assessment. Additionally, the facility failed to ensure a safe environment for residents who smoke. Two residents who required the use of a wheelchair and had mobility impairments were required to sign out on a leave of absence and navigate unassisted through the parking lot, over speed bumps, and across potholes to reach an off-premises smoking area. Observations confirmed that no staff supervision or smoking receptacles were present in the area where these residents smoked. One resident was observed struggling to move her wheelchair over a speed bump, and both residents expressed concerns about the difficulty and safety of accessing the designated smoking area. Review of the facility's policies and staff interviews indicated that smoking assessments were completed without direct observation of residents smoking, and staff were unclear about the requirements for supervision and safe smoking practices. The facility's policy stated that resident supervision should be based on individual assessments and physician orders, but in practice, residents with mobility and cognitive impairments were left unsupervised in potentially hazardous environments, leading to avoidable risks and incidents.