Failure to Complete Post-Fall Evaluations and Secure Oxygen Tanks
Penalty
Summary
The facility failed to complete required evaluations after residents sustained falls, as outlined in their own policy. Specifically, two residents who were identified as high risk for falls experienced multiple falls, but there was no documented evidence that post-fall evaluations were conducted within the required timeframe. Additionally, the care plans for these residents were not revised to include new individualized interventions following each fall, despite repeated incidents. Interviews with nursing staff confirmed the absence of documentation for both the evaluations and care plan updates after the falls occurred. Furthermore, the facility did not ensure that oxygen tanks were properly secured according to policy. Observations revealed that a portable oxygen tank was found free standing on the floor in a resident's room on two separate occasions, rather than being strapped to a cylinder stand or stored in the designated cage. Staff interviews confirmed that the oxygen tanks should have been secured as per facility policy, but this was not done.