Failure to Implement Fall Interventions and Secure Hazardous Chemicals
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions and post-fall assessments for two residents. One resident, with diagnoses including dementia, insomnia, and a history of falls, was care planned to have a floor mat at bedside as a fall prevention measure. Observation revealed that the floor mat was not present in the resident's room, and this was confirmed by an LPN, indicating the intervention was not in place as required by the care plan. Another resident, with multiple diagnoses including cerebral infarction, diabetes, and cognitive impairment, experienced an unwitnessed fall and was transported to the hospital. Review of the medical record showed that no post-fall assessment was documented after the resident returned from the hospital, a fact confirmed by the DON several hours after the incident. Additionally, the facility failed to ensure hazardous chemicals were properly stored and inaccessible to residents on the memory care unit. Observation found that cabinets behind the nurses station were left unlocked and unattended, containing items such as nail polish, nail polish remover, medication disposal compounds, bleach, disinfectant wipes, stainless steel cleaner, and needles. An LPN confirmed that all residents on the unit wandered and had access to these chemicals while staff were occupied in a resident's room. Review of the MSDS for these chemicals indicated potential for irritation, toxicity, and other health hazards upon exposure. These deficiencies affected multiple residents, including those with cognitive impairments and histories of wandering, and were identified through observation, interviews, record reviews, and policy and MSDS reviews. The facility's failure to implement care planned interventions, complete required assessments, and secure hazardous materials resulted in non-compliance with safety and accident prevention standards.