Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for several residents. Two residents with significant cognitive and physical impairments were observed lying in beds that were left in the highest position, contrary to their care plans which required beds to be in the lowest position when unattended. Both residents had diagnoses including dementia and other conditions affecting mobility and cognition, and their care plans specifically identified the need for bed safety interventions due to their risk of falls. Staff confirmed that the beds were left elevated after providing care and acknowledged forgetting to return them to the lowest position, despite being in-serviced on this safety protocol. Additionally, the facility failed to prevent resident-to-resident altercations and to secure potentially hazardous equipment. Two cognitively impaired residents, both with dementia and a history of wandering, were involved in a physical altercation in a common area, where one resident struck the other with a broom, resulting in a fall. The incident occurred in an area where residents had unsupervised access to housekeeping carts containing brooms and other cleaning equipment. Multiple observations revealed that housekeeping carts containing cleaning chemicals and equipment were left unattended and accessible to residents in various wings of the facility. Supervisory staff confirmed that these carts should not have been left unlocked or unattended, especially given the presence of residents with dementia who could access hazardous items. The facility's own policy required the environment to be as free of accident hazards as possible and for residents to receive adequate supervision, but these requirements were not met in the instances described.