Failure to Prevent Accident Hazards and Ensure Safe Transfers
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents. In the first instance, a resident with moderate cognitive impairment and a diagnosis of dementia was found to have an antimicrobial antiseptic skin cleanser in her room on two separate observations. The resident was unaware of who placed the bottle in her room or its intended use. Interviews with staff, including an LVN, the Director of Nurses, and the Administrator, confirmed that such items are prohibited in resident rooms due to the risk of harm, especially for residents with cognitive impairment. Despite this, the item remained in the resident's room, and facility policies provided did not specifically address the prohibition of such chemicals in resident rooms. In the second instance, a resident with severe cognitive impairment, hemiplegia, and a history of falls required two-person assistance with mechanical lift transfers. During an observed transfer, CNA B and CNA C did not maintain the mechanical lift legs in the wide position while moving the resident from his wheelchair to the bed. CNA B was unsure of the purpose of spreading the lift legs and routinely moved the resident with the lift legs in the narrow position. CNA C and the DON both stated that the lift legs should be in the wide position for stability and safety, as per facility policy and FDA best practices. The Administrator also confirmed that the staff did not follow the correct procedure, which could have compromised the resident's safety. Record reviews showed that CNA B had previously demonstrated satisfactory performance in mechanical lift procedures, which included keeping the lift legs in the wide position during transfers. Facility policy and FDA guidance both require the lift base to be at its maximum open position to ensure stability and prevent accidents. Despite this, the observed transfer did not adhere to these protocols, and the staff involved were not fully aware of the safety rationale behind the procedure.