Failure to Remove Hazardous Items and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision for a resident with dementia, psychotic disturbance, visual hallucinations, and anxiety disorder. The resident was found in possession of nine double-bladed disposable razors and one pair of tweezers in her room, despite facility policy requiring staff to identify and prevent accident hazards and to supervise residents according to their assessed needs. Staff were aware the resident had tweezers but were unaware of the razors, and indicated discomfort entering the resident's room due to her combative behavior. The resident had visible redness, inflammation, and scabs on her upper lip, which she attributed to tweezing, and expressed concerns about needing to protect her belongings from others. Interviews with staff confirmed that the presence of razors and tweezers in the resident's room was a safety concern, particularly given her cognitive and behavioral diagnoses. The Director of Nursing was surprised staff knew about the tweezers and confirmed that such items should not be accessible to the resident. The facility's failure to remove these items and provide appropriate supervision created a situation where the resident could have caused harm to herself or others.