Failure to Implement Fall Precautions and Proper Oxygen Tank Storage
Penalty
Summary
The facility failed to implement a care planned fall precaution intervention for a resident with multiple comorbidities, including dementia, reduced mobility, and severe cognitive impairment. The resident was observed on multiple occasions lying in bed with the bed height visibly elevated, approximately 2.5 feet from the floor, despite the care plan specifying that the bed should be in the lowest position when the resident is lying in bed. The bed controller was consistently out of the resident's reach, and staff incorrectly stated that the resident was care planned for a high bed, which was not documented in the care plan. Additionally, the facility failed to perform the resident's fall risk assessment on a quarterly basis as required, with the most recent assessments not aligning with the expected schedule. The facility's own policy requires fall risk evaluations upon admission, quarterly, annually, and with significant changes in condition, and mandates individualized fall precautions for residents at risk. The policy also emphasizes the importance of maintaining an environment free from hazards and providing appropriate supervision. Interviews with staff confirmed that the bed should be kept in the lowest position to minimize injury in the event of a fall, and that regular fall risk assessments are necessary to identify changes in residents' needs. In a separate incident, the facility failed to secure a resident's oxygen tanks in a proper holder. Two oxygen cylinders were observed leaning against the wall in a resident's room, not placed in a holder as required by facility policy. Staff confirmed that oxygen tanks should not be free-standing and must be stored in a holder or on a designated rack to prevent accidents. The improper storage of oxygen tanks was acknowledged by multiple staff members, including the DON, who stated that the purpose of using a holder is to ensure resident safety.