Failure to Secure Hazardous Chemicals and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to secure hazardous cleaning chemicals in a locked area, leaving disinfectant bleach wipes and a Clorox spray bottle accessible in an unsecured cabinet on the 300 Hall. These chemicals were labeled with warnings indicating they were hazardous to humans and should be kept out of reach of children. Eight cognitively impaired, independently mobile residents had access to this area. Staff interviews confirmed that facility policy required chemicals to be locked up, but this was not followed at the time of observation. A resident with severe cognitive impairment, chronic kidney disease, emphysema, muscle weakness, and a history of falls experienced a non-injury fall during a transfer. Staff failed to lock the brakes on the resident's wheelchair before attempting the transfer, causing the wheelchair to move and resulting in the resident being assisted to the ground. The care plan for this resident required staff to lock wheelchair brakes before transfers, and staff had been educated on this procedure, but it was not followed during the incident. Another resident with diabetes, renal failure, cognitive impairment, and a history of falls was observed sitting in a recliner with their call light and personal items out of reach, contrary to the care plan interventions. The care plan specified that the call light and needed items should be within reach and that staff should encourage the resident to call for assistance. Staff interviews confirmed that it was everyone's responsibility to ensure fall interventions were in place as care planned, but these interventions were not implemented at the time of observation.