Failure to Secure Hazards and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision and implementation of fall prevention interventions for multiple residents. Observations revealed that a room labeled 'Staff Only' containing five unlocked electrical panels with high voltage warnings was left unsecured and accessible from the central hallway. Staff confirmed that the room should have been locked at all times to prevent resident access to potential hazards, but it was found propped open during inspection. Several residents with cognitive impairments and histories of falls did not have their fall prevention interventions properly implemented. One resident, who was dependent on staff for mobility and had a history of falls, was repeatedly observed with her call bell and bedside table out of reach, despite care plans requiring these items to be accessible. The facility's call light system had been nonfunctional for an extended period, and the alternative call bell provided was not consistently within the resident's reach. Another resident, who used a walker and had mild cognitive impairment, was observed multiple times with his call light stuffed under his mattress and out of reach, contrary to care plan instructions. A third resident with severe cognitive impairment and a history of falls was found with his fall mat folded at the end of the bed rather than in place as required by his care plan. Staff interviews confirmed that all nursing staff were responsible for ensuring fall interventions were in place, but there was inconsistency in access to care plans and communication of interventions. Facility policies required a safe environment and adherence to fall prevention interventions, but these were not consistently followed, placing residents at risk for preventable accidents and injuries.