Failure to Prevent Accidents and Secure Hazards for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for several residents. In one instance, a resident with Alzheimer's disease, dementia, and osteopenia, who was at high risk for falls, experienced a fall in her room after turning off the lights. The fall resulted in a right hip fracture. The facility's fall investigation did not include staff interviews to determine the root cause or other contributing factors, and the care plan was not updated to reflect the use of a walker and wheelchair as interventions after the resident returned from the hospital. The intervention to maintain adequate lighting was not new and had been in place prior to the fall, but the investigation did not address why the resident was able to turn off the lights or if additional measures were needed. Another resident with dementia, unsteadiness, and muscle weakness experienced a fall attributed to worn non-skid socks that lacked sufficient grip. The facility provided these socks, which were shared and cleaned between residents, but staff did not routinely check their condition before use. The only immediate intervention after the fall was replacing the socks with a new pair. The care plan did not address the need for routine inspection or replacement of facility-provided footwear, and the fall investigation did not identify or implement additional preventive measures. A third resident, who was cognitively intact but had bilateral above-knee amputations and muscle wasting, was assessed as unsafe to smoke and required supervision. Despite this, the resident was observed with two lighters within reach at the bedside, contrary to the facility's smoking policy, which required all smoking paraphernalia to be maintained by staff and locked away. Staff interviews confirmed that even safe smokers were not permitted to keep lighters or smoking materials on their person, and the policy required staff to secure all such items. The presence of lighters at the bedside represented a failure to follow the facility's own safety protocols.