Failure to Complete Safety Assessments and Ensure Use of Assistance Devices
Penalty
Summary
The facility failed to complete a safety assessment for a resident who used an electric lifting recliner chair. This resident, who was cognitively intact but required staff assistance for daily care and had chronic kidney disease, was found on his knees facing his recliner with his upper body resting on it after attempting to get up to ring his call bell. Documentation indicated that the resident had poor safety awareness and impulsive behaviors, yet no safety assessment specific to the use of the electric lifting recliner chair was completed for him. Additionally, the facility did not ensure that appropriate assistance devices were in place for another resident who was severely cognitively impaired, required assistance with daily care, and used a wheelchair for mobility. This resident was observed being transported by a hospitality aide without leg rests on her wheelchair, resulting in one foot dragging on the floor. The aide stated that she did not use leg rests because the resident could self-propel and was unsure if foot petals were available. The DON confirmed that leg rests should have been used during transport if the resident could not lift her feet off the floor.