Failure to Maintain a Hazard-Free Environment and Proper Supervision
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision in the facility. Several residents who were assessed as high risk for falls had fall mats placed at their bedsides as an intervention. However, observations revealed that furniture and medical equipment, such as overbed tables, wheelchairs, and even an unoccupied bed, were placed on top of these fall mats for multiple residents. Staff interviews confirmed that these items should not be on the mats, as they compromise the mats' effectiveness in reducing injury from falls and could cause additional harm if a resident were to fall onto a hard object or a mat with diminished cushioning. In addition to the improper use of fall mats, one resident was found to have medication, specifically Ammonium Lactate 12% moisturizing lotion, left at the bedside. This medication had been brought from the hospital and was not reconciled or stored according to facility policy. Staff acknowledged that medications should not be left at the bedside to prevent accidental overdose or access by other residents, and that all medications should be checked and stored securely in the medication room. The report also documents that care plans and physician orders for fall prevention interventions were not always updated or implemented as recommended by the interdisciplinary team. For example, a resident who required a customized or reclining wheelchair for postural support and fall prevention was observed using a regular wheelchair shared with other residents, and the care plan was not updated to reflect the recommended intervention. These lapses in following care plans and ensuring a hazard-free environment contributed to the deficiencies cited by surveyors.