Failure to Prevent Accidents and Secure Hazards
Penalty
Summary
The facility failed to protect residents from accident hazards and did not provide adequate supervision to prevent accidents. One resident with significant medical conditions, including heart disease, lymphoma, a history of falls, osteoporosis, and an above-the-knee amputation, was transferred from her bed to a wheelchair by a CNA without the use of the required slide board and without a second staff member assisting. The resident's care plan, posted instructions, and therapy documentation all specified that a slide board and two-person assist were necessary for safe transfers. Despite this, the CNA attempted a stand-and-pivot transfer, which the resident could not safely perform due to her single leg and pain, resulting in a fall and a fractured ankle that required emergency room treatment. Additionally, the facility did not ensure the safety of shower rooms, as two out of three rooms were observed to have unlocked and open cabinets containing new disposable razors and an overfilled sharps container with used razors protruding from the opening. These items were easily accessible to residents, creating a risk of injury. Multiple staff, including a licensed nurse, the assistant director of nursing, and the director of nursing, confirmed that razors and sharps should not be left accessible in this manner. The facility's own policies and standard procedures, as well as external guidelines referenced by staff, required the use of proper equipment and secure storage of hazardous items to ensure resident safety. The observed failures directly resulted in a resident injury and created the potential for further harm to other residents.