Failure to Prevent Accident Hazards and Incomplete Resident Assessments
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not implement or update care plans and assessments to prevent accidents for three of four residents reviewed. One resident with a history of stroke and hemiplegia experienced a fall during a shower, resulting in a right hip fracture, and there was no fall care plan in place for this resident. The Director of Nursing Services (DNS) confirmed that the resident was showered in a different stall than usual, with grab bars on the resident's weaker side, and acknowledged that a fall care plan should have been implemented but was not. Another resident with diabetes and COPD had multiple falls, including one in the bathroom without footwear, and was observed without proper footwear and with the bed against the wall, which was not care planned, assessed, or consented. The DNS confirmed that new interventions were not added to the fall care plan after repeated falls and that the bed against the wall lacked required documentation. A third resident, who was cognitively intact and permitted to smoke unsupervised, did not have a completed smoking safety evaluation in their record. The DNS confirmed that the required safety assessment for independent smoking was missing and could not be found by therapy staff.