Failure to Complete Safety Assessments and Documentation for Safety Devices and Positioning
Penalty
Summary
The facility failed to complete required safety assessments and obtain necessary documentation for the use of certain safety devices and positioning interventions for multiple residents. For one resident with no memory impairment, the care plan included placing the bed against the wall, but there was no documented safety assessment to justify this intervention. Observation confirmed the bed was positioned against the wall, and staff interviews revealed an expectation for safety assessments in such cases, but none could be provided. Another resident with impaired memory and a history of falls was observed with fall mats on both sides of the bed. The care plan indicated the resident was at risk for falls, but there was no physician’s order, informed consent, or safety device assessment for the use of the floor mats. Staff confirmed that these steps were expected but had not been completed or documented for this resident. A third resident with multiple diagnoses, including stroke, impaired memory, and a history of falls, was using a tilt-in-space wheelchair. Although a safety device evaluation recommended the wheelchair for support and comfort, there was no therapy evaluation or safety assessment to determine the necessity and safety of the device. Observations showed the resident was unable to unlock the wheelchair brakes independently and expressed frustration at being unable to return to their room. Staff interviews confirmed the lack of required assessments and documentation for the use of the tilt-in-space wheelchair.