Failure to Prevent Accidents and Maintain a Safe Environment
Penalty
Summary
Facility staff failed to assess a resident's ability to safely spend time unsupervised on the courtyard patio and did not provide adequate supervision or a safe environment in that area. The resident, who had a history of congestive heart failure, muscle wasting, dementia, and cognitive impairment, was found unsupervised on the patio and sustained a fall resulting in a head injury, laceration requiring staples, and a cervical vertebral fracture. The resident's care plan did not address outdoor supervision, and multiple prior falls and high fall risk assessments were documented. Staff interviews revealed inconsistent understanding and documentation regarding the use of safety devices such as wander guards, and no evidence was found that the resident had been properly assessed for unsupervised outdoor access. Additionally, the facility failed to maintain a safe environment in the resident's bedroom, where a hazardous aerosol varnish spray was found. The material safety data sheet for the product indicated it was extremely flammable, hazardous, and carcinogenic, and staff acknowledged it should not have been accessible to residents. The presence of this substance in the resident's room was confirmed through observation and staff interviews. The facility also failed to provide a safe environment and adequate supervision to prevent accidents for another resident with a known history of unsupervised smoking. This resident caused a fire by discarding a lit cigarette in a trash can on the enclosed patio, resulting in property damage. Documentation and interviews indicated that the resident continued to access smoking materials and areas unsupervised, despite being identified as unsafe to smoke and having a history of wandering. The care plan and clinical record lacked appropriate interventions and monitoring for smoking-related hazards, and staff were inconsistent in their handling and storage of the resident's smoking materials.