Unsecured Sharps and Incomplete Fall Assessment Documentation
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, two disposable blue razors were found unsecured on the bathroom sink in the shared room of two residents. One resident was cognitively intact with a BIMS score of 13 and diagnoses including diabetes, bipolar disorder, depression, and pain. The other resident was moderately cognitively impaired with a BIMS score of 9 and diagnoses including Alzheimer's, schizophrenia, anxiety, and major depressive disorder. Both an LPN and the DON confirmed that razors should not be left unsecured in resident bathrooms, as per facility policy. Additionally, the facility failed to complete required fall assessment documentation for a resident who was moderately cognitively impaired and had diagnoses including dementia, heart failure, chronic kidney disease, hypertension, and diabetes. After this resident slid off the toilet onto the floor, the post-fall event documentation was found to be incomplete, with pages 2-9 left unfinished. The DON confirmed that the post-fall assessment should have been completed according to facility policy.