Failure to Prevent Accidents and Ensure Supervision for High-Risk Residents
Penalty
Summary
Multiple deficiencies were identified in the facility's management of accident hazards and supervision to prevent accidents among residents. One resident with a history of falls and poor safety awareness was provided a motorized wheelchair without a documented safety assessment at the time of receipt. This resident experienced several falls from the motorized wheelchair, including an incident resulting in a closed fracture of the fibula. The care plan was not updated to include interventions specific to the use of the motorized wheelchair, and therapy records did not address the resident's safety in using the device, despite repeated falls and documented poor safety awareness. Another resident, identified as being at risk for falls due to decreased cognition, weakness, and malnutrition, had a perimeter mattress ordered as a fall intervention. However, observations revealed that the perimeter mattress was not in place as required by the care plan, and no other fall interventions were visible in the resident's environment. This lack of implementation of care plan interventions was confirmed by facility staff during the survey. The facility also failed to ensure safe smoking practices and adequate supervision for residents requiring such oversight. Several residents who required supervision while smoking were observed out on the smoking patio without staff supervision, and some were found in possession of cigarettes and lighters, contrary to facility policy. Additionally, a resident with an order for leave of absence (LOA) was allowed to leave the facility without documenting an expected time of return, and staff did not consistently monitor the LOA log or follow up in a timely manner when the resident did not return as expected. These lapses in supervision and policy adherence affected multiple residents and were confirmed through record review, staff interviews, and direct observation.