Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
Surveyors identified deficiencies related to accident hazards and inadequate supervision for two residents. One resident with chronic obstructive pulmonary disease (COPD) and heart failure had a physician's order for continuous oxygen via nasal cannula. On observation, the resident's oxygen concentrator was left running at 4 liters per minute in the room while the resident was not present, and the nasal cannula was left on the bed. The resident confirmed not using portable oxygen during certain activities, and both a CNA and the Director of Nursing verified that the concentrator should have been turned off when not in use, as per facility policy and safe oxygen use guidelines. Another resident with dementia, mobility issues, and a history of falls was observed being encouraged by the Maintenance Director to transfer independently from a wheelchair to bed, despite the care plan specifying the need for one-person assistance during transfers. The Maintenance Director did not check the care plan before encouraging the resident to self-transfer and later acknowledged this oversight. A CNA confirmed the resident should have assistance, and the Director of Nursing stated that the Maintenance Director should not have facilitated or encouraged the transfer.