Failure to Prevent Accidents and Ensure Medication Safety
Penalty
Summary
The facility failed to prevent accidents and implement appropriate interventions for residents at risk for falls and injury. One resident with a history of falls and a care plan requiring bilateral side rails was moved to a new room without the side rails or alternative interventions in place. This resident subsequently rolled out of bed, sustained a head laceration and a humeral head fracture, and required orthopedic evaluation. Documentation showed that the need for side rails or other interventions was not reassessed or implemented after the room change, despite the resident's known fall risk and previous similar incidents. Two additional residents with repeated falls and injuries did not have new interventions implemented or documented after their respective falls. One resident fell in the hallway while seeking assistance and sustained a right hip fracture, but the care plan was not updated with new interventions addressing the root cause. Another resident was found on the floor in his bathroom and later diagnosed with a right femoral neck fracture, yet the record lacked documentation of interdisciplinary team follow-up or new interventions to prevent future falls. The facility's fall prevention policy requires root cause analysis and new intervention strategies after each fall, but this was not followed for these residents. The facility also failed to prevent potential accidents related to medication safety. Multiple residents were found with medications at their bedside without orders or assessments for self-administration. One resident had topical medication on the nightstand, another had an inhaler and an over-the-counter medication without an order, and two residents with cognitive impairment had pills accessible in their rooms. Records lacked up-to-date self-administration assessments for these residents, and facility policy requires that staff remain with residents to ensure medications are taken as prescribed. These lapses created the potential for medication errors and harm.