Failure to Prevent Accident Hazards Due to Unsafe Items in Resident Rooms
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards for three residents, as evidenced by the presence of potentially dangerous items in their rooms. One resident, with a history of dementia, lack of coordination, and chronic pain, was repeatedly observed with a large pair of nail clippers and tweezers on her bedside table. Staff interviews revealed inconsistent understanding and enforcement of facility policy regarding residents' possession of such items, with some staff stating that no residents were allowed to cut their own nails or possess nail clippers or tweezers, while others referenced the resident's cognitive status as a factor in allowing possession. The facility's care plan for this resident indicated a need for supervision with personal hygiene, but the items remained accessible over multiple days. Another resident, with moderate cognitive impairment, muscle weakness, and a history of falls, was found with a pair of sharp scissors and a disposable razor on her bedside table. The resident stated she used the scissors for eating candy and could use the razor with one hand. Staff confirmed that the resident did not shave herself and that such items should not be left at the bedside, indicating a lapse in supervision and room checks. The items were believed to have been brought in by family, but staff were unclear on their origin and only removed them after being alerted. A third resident, with mild cognitive impairment and a history of altered mental status, was found with an all-purpose cleaner in her restroom. The cleaner was not facility-issued, and housekeeping staff stated it was not their product. Nursing staff and the DON confirmed that chemicals were not allowed in resident rooms, and that all staff were responsible for removing prohibited items. The presence of the cleaner was attributed to possible family involvement, but it remained in the resident's room until discovered during the survey. Facility policy review indicated a requirement for a safe environment and proper handling of personal hygiene equipment, but these were not consistently followed.