Failure to Prevent Accidents and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate supervision and implement fall prevention interventions for multiple residents, resulting in several deficiencies related to accident hazards and resident safety. One resident with a history of chronic conditions, including dementia and Parkinson’s disease, was observed in his room without appropriate fall prevention measures such as floor mats or a call light within reach, despite being identified as high risk for falls. The resident’s bed was unplugged, and unsafe items, including a G-tube plunger not belonging to him, were present in the room. The care plan indicated interventions like keeping the bed in the lowest position and ensuring the call light was accessible, but these were not in place at the time of observation. The resident had experienced multiple falls in the year, and staff were unable to specify which interventions were in place prior to the most recent fall. Another resident, who had recently undergone a leg amputation and was identified as high risk for falls, was found in bed without both required floor mats in place, with the bed not in the lowest position, and a wet floor nearby. The resident expressed concern about the lack of side rails, which staff acknowledged but had not communicated to administration. Staff confirmed that both floor mats should have been in place and that the bed should have been lowered, but these interventions were not consistently implemented. Additional deficiencies were observed in the supervision and assistance provided to residents in communal areas. One resident was seen in the dining room with improperly worn shoes, and staff failed to address this until prompted. Another resident was observed with only one shoe and a sock with holes, and staff did not offer assistance or alternative footwear. A further resident was found in a hallway with pants pulled down and one foot exposed, with staff failing to address privacy or safety concerns until questioned. The dining room was also left unsupervised with multiple residents present, and a persistent water leak created a slipping hazard that was not adequately managed. These findings demonstrate a pattern of inadequate supervision, failure to implement care plan interventions, and unaddressed environmental hazards.