Failure to Prevent Accidents and Maintain a Safe Environment
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards, resulting in avoidable accidents involving five residents. One resident, a bilateral amputee with paraplegia and neurogenic bladder, was electrocuted while lying in bed after urine contacted an energized power strip that had been provided by the Administrator and placed in the resident's bed. This incident resulted in third-degree burns to 4% of the resident's body. Staff and other residents reported that the resident frequently kept electronic devices and cords in bed, and concerns about safety had been voiced to administration, but no effective interventions were implemented to prevent the accident. Staff interviews revealed a lack of clear procedures for approving and monitoring electrical devices, and maintenance did not keep logs or have a set schedule for checking cords and devices. Another resident, who was cognitively impaired, legally blind, and at high risk for falls, was left unattended in the bathroom after being assisted there by staff. The resident stood up and fell, sustaining a left pubic root fracture that resulted in a fatal hemorrhage. The cause of death was documented as blunt force injury of the pelvis. The resident's care plan identified a high risk for falls and required staff assistance with transfers, but staff failed to provide the necessary supervision at the time of the incident. The resident had a history of falls and required substantial assistance with mobility and activities of daily living. Additional residents were observed with electrical devices and charging cords in their beds or attached to bed rails, despite care plans noting noncompliance with electrical device safety. Staff and residents reported that concerns about electrical hazards were not addressed until after state surveyors were present. Facility documentation revealed a lack of policies and procedures for testing patient care-related electrical equipment according to NFPA standards, and numerous devices with deficiencies were identified without records of repair. Staff education on electrical safety was inconsistent or lacking, and there was no evidence of systematic monitoring or enforcement of safety protocols related to accident hazards.