Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for two residents. One resident, who had a history of falls, confusion, impaired gait and balance, and was assessed as high risk for falls, was observed with their bed in a high position despite care plans and physician orders specifying the bed should be kept in the lowest position. Multiple staff interviews confirmed that the bed should have been kept low to prevent falls, and facility documentation indicated this intervention was part of the fall prevention protocol. The resident had previously experienced an unwitnessed fall, and assessments consistently identified them as high risk for further falls. Another resident, with a history of major depressive disorder and previous falls, was allowed to keep cigarettes and a lighter in their possession, contrary to facility policy and care plan interventions. The resident was supposed to have smoking materials stored securely by staff or in a safety box, but the safety box was not provided, and the resident retained both cigarettes and a lighter in their room. Interviews and observations confirmed the resident kept these items, and staff acknowledged that this was not in line with facility safety protocols, especially given the presence of other residents on oxygen in nearby rooms. Facility policies required individualized plans for safe storage and supervision of smoking materials, and staff were aware of the risks associated with residents keeping lighters and cigarettes in their rooms. Despite this, there was no effective plan implemented to ensure the safe storage of these items for the resident, and staff did not consistently follow up to retrieve smoking materials after use. This failure to follow established protocols and care plans resulted in an environment with preventable accident hazards for both residents.