Failure to Prevent Accident Hazards and Enforce Safety Policies
Penalty
Summary
The facility failed to provide a safe environment free from accident hazards for multiple residents by not implementing its own policies related to accident prevention and hazard control. For one resident with a seizure disorder and orders for padded side rails, the side rail padding was repeatedly observed improperly positioned on the outside of the rail, rather than secured inside as required. Staff interviews confirmed that the padding was loose and not correctly attached, and that the issue had not been addressed despite ongoing use of the padding for seizure safety. Another resident, who was cognitively intact but had significant physical impairments and a history of behavioral issues, was found to have a bladed box cutter on the bedside table. Staff acknowledged that the resident had been previously instructed not to keep such items, but the box cutter had not been detected during routine checks or after the resident returned from a day pass. The resident admitted to purchasing and using the box cutter for personal activities, and staff interviews revealed inconsistent practices regarding the search of residents' belongings and enforcement of the facility's policy prohibiting weapons and hazardous items. Additional deficiencies included two residents at risk for falls who did not have required bilateral floor mats in place while in bed unattended, contrary to physician orders and care plan interventions. In both cases, staff removed the mats for meal setup and failed to replace them, leaving the residents unprotected. Another resident with severe cognitive impairment and nicotine dependence was observed keeping cigarettes in personal possession, in violation of the facility's smoking policy, which requires all smoking materials to be secured by staff. Staff interviews confirmed that cigarettes were distributed to the resident and not always returned or accounted for as required by policy.