Failure to Maintain Safe Environment and Follow Care Plan for Fall Risk Residents
Penalty
Summary
The facility failed to follow a resident's plan of care and did not recognize or address accident hazards in the patio area. One resident with significant musculoskeletal impairments, including left hemiplegia, muscle weakness, and a history of repeated falls, was dependent on staff for wheelchair mobility and required a leg strap to prevent the left leg from falling off the wheelchair footrest. Despite care plan interventions specifying the use of a leg strap, the resident was observed multiple times without the strap, and both nursing and aide staff were unaware of its whereabouts. The resident reported previous incidents of the left leg falling out of the footrest, particularly when traversing the ramp in the patio area, which was described as uneven and cracked. Observations and interviews revealed that the patio ramp had multiple cracks and uneven surfaces, with height differences of up to 0.75 inches, causing difficulties for several residents using wheelchairs and rollators. Multiple residents, all identified as fall risks, experienced their mobility devices getting caught on the cracks, and one resident nearly tipped over as a result. Staff and residents reported that the ramp had been a known hazard for an extended period, with loose pieces of cement present. The facility's own policies required regular environmental safety audits and removal of hazards, but these were not effectively implemented, resulting in ongoing risks to residents' safety.