Failure to Prevent Accident Hazards and Ensure Resident Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents. One resident, who was on continuous oxygen therapy and had a history of heart failure, hypertension, and COPD, was repeatedly found smoking while oxygen was being administered. Despite being care planned as a current smoker at risk for adverse effects and having a behavioral contract in place, the resident was observed smoking with oxygen in use on multiple occasions, both on facility premises and in the adjacent building's parking lot. Staff interviews confirmed that the resident continued to smoke with oxygen, and interventions such as education and behavioral contracts did not prevent the behavior. Documentation showed that the resident had cigarettes and a lighter in his room, and staff were aware of his noncompliance but did not implement further effective interventions. Another resident, who had a history of falls, Parkinsonism, and severe cognitive impairment, was found with a bed rail/assistance bar detached and lying on the floor next to his bed. The resident required substantial assistance with activities of daily living and was considered a fall risk. Staff observed the detached bed rail and reported it to the Maintenance Director, who repaired it after being notified. The care plan for this resident included interventions for fall risk, such as a low bed and fall mats, but did not specifically address the secure attachment of the bed rail. Interviews with staff and the Maintenance Director confirmed that the bed rail had become detached due to a missing screw and that all staff were responsible for reporting such hazards. The deficiency was identified through observation, interview, and record review, revealing that the facility did not provide adequate supervision or ensure the implementation and monitoring of interventions to prevent accidents. The lack of effective follow-up and modification of interventions for residents who were noncompliant with safety policies, as well as the failure to ensure the secure attachment of safety devices, exposed residents to potential harm, injury, or death due to inadequate monitoring and hazard prevention.