Failure to Secure Hazardous Materials and Provide Supervision During Meals
Penalty
Summary
The facility failed to secure pressurized supplemental oxygen tanks and hazardous cleaning chemicals in locked areas, leaving them accessible in unlocked closets within the dining area and adjacent storage spaces. Thirteen fully pressurized oxygen cylinders were observed stored in floor racks in an unlocked supply closet, and unsecured cleaning chemicals labeled as hazardous were found in a nearby storage closet. Staff interviews confirmed that these areas were expected to be locked at all times, but staff sometimes forgot to fully close the doors, resulting in the materials being accessible to residents, including those with cognitive impairments. Additionally, the facility did not provide consistent supervision to a resident with severe cognitive impairment, Alzheimer's disease, and significant ADL deficits during mealtimes. The resident's care plan required staff to supervise her during meals, encourage her to eat in the dining room, and ensure her call light was always within reach. However, multiple observations showed the resident eating alone in her room without staff present, with her call light out of reach under her bed, and her nutritional supplement left with her meal. Staff interviews confirmed that supervision and call light accessibility were required per the care plan, but these interventions were not consistently implemented. Facility policies required hazardous materials and oxygen to be secured and inaccessible to residents, and for residents to have access to a call system at all times. The facility's fall management and call light policies also emphasized the need for supervision and minimizing accident risks, but these were not followed, resulting in residents being exposed to preventable hazards and lacking necessary supervision.