Failure to Prevent Accidents and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure that a shower room was free from accident hazards and provided adequate supervision, as evidenced by a wheelchair-bound resident being left alone in the shower room for 45 minutes without access to a call light pull cord. The call light station was not only missing the required pull cord but was also out of reach due to obstructing shower chairs, creating a hazardous environment. Staff confirmed that residents should not be left unattended in the shower room and that the lack of call light accessibility was unsafe. Another resident, identified as having a high risk for falls, did not consistently have fall prevention interventions in place. Observations revealed that the resident's fall mat was folded and not positioned on the floor as required, and the call light was not within reach, with its button hidden behind the mat. The resident was observed attempting to get out of bed without assistance, and the bed was found to be unlocked on multiple occasions. Staff interviews indicated that interventions such as ensuring the call light was within reach and the fall mat was in place were not always followed, and concerns about the adequacy and consistency of fall prevention measures were raised by both staff and family. A third resident experienced multiple falls, some resulting in head injuries, with documentation indicating possible causes such as orthostatic hypotension, dehydration, and a potential seizure. Despite these incidents, observations showed that the resident did not have water readily available at the bedside and was not using prescribed oxygen. The facility's fall prevention policy required individualized interventions and routine rounding, but the lack of consistent implementation of these measures contributed to the resident's repeated falls and injuries.