Failure to Implement and Maintain Resident Safety Measures
Penalty
Summary
The facility failed to implement and maintain safety measures and interventions to prevent accidents and hazards for multiple residents. One resident with dementia and Alzheimer's disease, who was assessed as having impaired cognitive function and limited fine motor skills, was allowed to smoke without the required protective smoking apron. This resulted in the resident dropping a cigarette on his lap and sustaining a full-thickness burn with 100% slough, necessitating debridement. The resident's care plan specified the need for a smoking apron and direct supervision during smoking, but these interventions were not followed. Additionally, the smoking materials box at the nurse's station was left unlocked and unattended, making cigarettes and lighters accessible to other cognitively impaired, independently mobile residents. Another resident with a history of falls, cognitive impairment, and dependence on staff for mobility was found multiple times with the call light out of reach, including behind the headboard and inside a closed nightstand drawer. This resident had experienced several falls since admission, and the care plan required the call light to be within reach at all times. Staff interviews confirmed that the resident could not access the call light when it was not properly positioned, and staff were unable to account for how the call light was placed out of reach. A third resident, also with cognitive impairment and a history of falls, was observed without a required non-skid pad (dycem) in the recliner and with the call light not within reach. The care plan included specific fall prevention interventions, such as the use of a dycem and ensuring the call light was accessible. Staff were unaware of the required interventions and could not locate them in the resident's chart. These failures in implementing and maintaining individualized safety interventions directly contributed to accident hazards and actual harm.