Failure to Prevent Accident Hazards, Unsafe Smoking Practices, and Inadequate Elopement Supervision
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for its residents. Specifically, hot water temperatures in six out of eight resident bathroom sinks were found to be excessively high, ranging from 121.6°F to 136.7°F, which exceeded the facility's policy limit of 120°F. Residents affected included individuals with severe cognitive and visual impairments, such as schizoaffective disorder, dementia, and Alzheimer's disease, who were able to access the bathrooms independently. Staff confirmed that daily random water temperature checks were performed, but the temperatures remained above the safe threshold, and the facility's policy on water temperature was not effectively implemented. The facility also failed to ensure safe smoking practices and did not enforce its smoking policy. Multiple residents were allowed to keep lighters and cigarettes in their possession within the resident care areas, despite facility policy requiring all smoking materials to be stored at the nursing stations. One resident was observed igniting a lighter in her room while her roommate was actively receiving continuous supplemental oxygen, directly violating the facility's oxygen therapy and smoking policies. Interviews with residents and staff confirmed that several residents routinely kept smoking materials in their rooms or on their person, and staff were aware of this practice. Additionally, the facility did not provide adequate supervision to prevent elopement for two residents identified as high risk. One resident with a history of wandering and severe memory impairment eloped from the facility and was found over a mile away after more than two hours. Documentation and investigation of the incident were lacking, and the resident's care plan was not updated with effective interventions. Another resident also eloped, and staff interviews revealed that supervision and documentation were insufficient to prevent or address the incident. The facility's policy on wandering and elopement was not consistently followed, as required assessments, notifications, and care plan updates were not completed.