Failure to Maintain Safe Environment and Prevent Accident Hazards
Penalty
Summary
The facility failed to provide a safe environment in accordance with its own policies regarding accident hazards for two vulnerable residents. For one resident with a history of falls and significant cognitive impairment, observation revealed that while the resident was in bed, a required floor mat was not properly positioned; instead, it was placed against the wall rather than beside the bed as ordered. Staff interviews confirmed that floor mats are to be placed on both sides of the bed when the resident is in bed, and stored away only when the resident is out of bed. The resident’s care plan and physician’s orders specifically required bilateral floor mats due to the resident’s high risk for falls and decreased safety awareness. For another resident with severe cognitive impairment and total dependence for activities of daily living following a cerebral infarction, an open container of disinfectant wipes was found on the bedside table. The wipes contained hazardous chemicals, including high concentrations of ethyl alcohol and quaternary ammonium compounds, with manufacturer warnings indicating the need for secure storage. Staff interviews confirmed that such disinfectant wipes are not permitted in resident rooms due to the risk of inappropriate use, especially for residents who are not alert and oriented. Facility policy also prohibits hazardous items from being kept in resident rooms and requires staff to routinely check for such hazards. Both incidents were identified through direct observation, record review, and staff interviews, demonstrating a failure to adhere to facility policies and procedures designed to minimize accident hazards and ensure resident safety. The deficiencies involved lapses in environmental safety checks and improper storage of hazardous materials, directly affecting residents with significant cognitive and physical impairments.