Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to implement new interventions to reduce fall incidents for a resident with chronic pain, diabetes, and dementia. After an unwitnessed fall resulting in a left femur fracture and subsequent surgery, there was no documentation of the incident in the March incident log, and the resident's care plan was not updated with new interventions following the fall. The care plan was only revised after a second unwitnessed fall in April, when an intervention to encourage the resident to use the call light for assistance was added. Additionally, the facility did not ensure elopement precautions were in place for one hall. A resident exited the facility through a gym door to a patio area, which had an unlocked gate leading to the parking lot and another to a city street. The door alarm was not functioning, and staff confirmed that the gates were not locked, allowing residents to leave the property. Furthermore, a medication cart was observed unsecured in a hallway with residents nearby, making medications accessible to residents and visitors. Staff acknowledged that the cart should have been secured.