Failure to Prevent Resident Access to Hazards and Inadequate Hot Liquid Safety
Penalty
Summary
Facility staff failed to provide adequate supervision and maintain an environment free from accident hazards, resulting in multiple incidents of resident harm. One resident with severe dementia ingested an unknown amount of body wash that had been left accessible on her bedside table. This resident was known to be impulsive, grab at objects, and was not oriented, requiring total care. Staff interviews and clinical documentation confirmed that the body wash was left within reach after a bed bath, and the resident subsequently ingested it, leading to respiratory distress, hospitalization, intubation, and the need for a tracheostomy and feeding tube. The incident was not directly witnessed, but multiple staff and the resident's roommate confirmed the presence of the body wash and the resident's symptoms following ingestion. Additionally, the facility did not have a system or protocol in place to monitor the temperature of hot liquids served to residents. This failure resulted in another incident where the same resident spilled hot coffee on herself, causing redness and requiring medical attention. Review of the resident's hot liquid safety evaluation revealed inaccuracies and omissions, as the assessment did not reflect the resident's documented agitation, impulsivity, and behavioral symptoms. Staff interviews confirmed that coffee temperatures were not routinely checked, and observations during the survey found that coffee was being served at temperatures exceeding safe limits. Further observations during the survey revealed that hazardous items, such as toiletry products and cleaning supplies, were left unsecured in resident rooms and common areas, including shower rooms with open doors and accessible gallon jugs of shampoo and body wash. Residents with cognitive impairment and poor safety awareness were found to have access to these items, and staff interviews confirmed a lack of consistent practice regarding the storage of potentially hazardous materials. These deficiencies were found to have the potential to affect multiple residents across all nursing units.