Failure to Prevent Accident Hazards Related to Elopement and Smoking Materials
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, resulting in deficiencies related to elopement risk management and safe smoking practices. One resident with severe cognitive impairment, dementia, and anxiety disorder was identified as an elopement risk upon admission, with behaviors such as wandering, expressing a desire to go home, and staying near exits. Although the facility's policy required that residents at risk for elopement be included in an Elopement Risk Binder with their photograph and information, this resident was not added to the binder at the front desk or nurses' stations. Staff interviews confirmed that the resident's risk evaluation was not properly completed to indicate inclusion in the binder, and the required documentation and photograph were missing. Another resident, who was cognitively intact and a smoker, was found to have smoking materials, including a cigarette box, lighter, and used cigarettes, stored in the compartment of a rolling walker in their room. Facility policy required that all smoking materials be kept at the nurses' station and disposed of properly after use to prevent fire hazards. Staff confirmed that the resident should not have had smoking materials in their possession and that storing them in the walker was a fire hazard. Additionally, the facility failed to complete a required quarterly Safe Smoking Assessment for this resident, as indicated by a gap in the assessment schedule between two documented assessments. These deficiencies were identified through record reviews, staff and resident interviews, and direct observation. The facility's failure to follow its own policies regarding elopement risk management and safe smoking practices resulted in lapses in supervision and the presence of accident hazards for the affected residents.