Failure to Prevent Accidents and Secure Environmental Hazards
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident with severe cognitive impairment, a history of repeated falls, and multiple risk factors had several documented falls. Despite being identified as a high fall risk and having numerous care plan interventions in place, the facility did not consistently implement or monitor these interventions. Observations revealed that required safety signs were missing from the resident's room, and visual cues such as bright tape on wheelchair brakes were not present. Additionally, the facility was unable to provide root cause analyses or investigations for several of the resident's falls, nor could they provide evidence that medication reviews, as required by the care plan, were completed following these incidents. Environmental hazards were also identified throughout the facility. During inspections, surveyors found that the power shut-off for the kitchenette oven and stovetop was not activated, leaving the appliances operational and accessible to residents. A working toaster was also left plugged in and accessible. In another area, an unlocked maintenance closet contained multiple bottles of hazardous disinfectant cleaners. On the secured memory care unit, a cognitively impaired and independently mobile resident was observed rummaging through an unlocked cabinet containing bleach and disinfectant spray, with no staff supervision provided at the time. Staff interviews confirmed that hazardous materials and equipment were not consistently secured, and direct care staff were not trained on how to deactivate the oven/stovetop power. The facility's own policies required that hazardous materials be kept out of residents' reach and that accident hazards be minimized through preventative interventions and supervision. However, these policies were not followed, as evidenced by the unsecured chemicals, accessible appliances, and lack of staff training. The failure to secure hazardous materials and equipment, combined with the lack of effective fall prevention interventions and monitoring, placed multiple cognitively impaired and independently mobile residents at risk for accidents and injuries.