Unsecured Hazardous Chemicals and Inadequate Supervision Leading to Resident Fall
Penalty
Summary
The facility failed to ensure that hazardous chemicals were not accessible to residents and did not provide adequate supervision to prevent accidents. Multiple unsecured chemicals were observed in various locations, including a spray bottle of floor cleaner on a housekeeper’s cart, plant food/fertilizer in a dining room, a spray bottle of sanitizer in an unlocked cabinet, and cleaning chemicals in an unsecured salon room. Additionally, a resident with sensory and perception alterations related to vision was found to have two cans of aerosolized insecticide in her room, which staff were unaware of and acknowledged should not have been accessible. Staff interviews confirmed that these chemicals should have been secured and not available to residents. The facility also failed to provide sufficient supervision to prevent a fall for a resident with a history of falls who required maximal assistance from two staff for transfers. Despite this care plan, a CNA attempted to transfer the resident alone, resulting in a witnessed fall. The DON confirmed that the resident’s fall care plan, which required two-person assistance for transfers, was not implemented at the time of the incident.