Failure to Prevent Accident Hazards and Secure Medications
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for three residents. One resident, with a history of falls and high fall risk, experienced a fall after tripping over a Foley catheter bag. The fall was witnessed by a CNA, who assisted the resident off the floor and reported the incident to the LPN on duty. However, the LPN did not assess, document, or report the fall, nor did she conduct a fall risk assessment or implement new interventions. The resident later complained of pain, and an x-ray revealed a left femoral neck fracture and a closed left hip fracture, which required surgical intervention. The facility's investigation confirmed that the nurse failed to follow policy regarding post-fall assessment and documentation, and the CNA moved the resident before a nurse assessment was completed. Additionally, the facility did not follow its policy on self-administration of medication for two residents. One resident was found with a pill bottle containing an unknown substance and an inhaler at the bedside, despite no physician order or care plan for self-administration. The resident reported using the inhaler multiple times daily and identified the pill bottle as eczema medication, but staff confirmed there were no orders for these medications and that the facility was unaware of their presence. The DON acknowledged that the medications should not have been at the bedside and that an assessment for self-administration was not completed. Another resident was observed with bottles of vitamin C, vitamin D3, and vitamin E at the bedside, which the resident reported taking independently. There were no physician orders, care plan, or interdisciplinary team approval for self-administration of these supplements. Nursing staff were unaware of the presence of these medications, and the DON confirmed that the process for allowing self-administration, including physician orders and care planning, was not followed. These failures resulted in unsecured medications at the bedside and a lack of oversight regarding the residents' medication regimens.