Failure to Maintain a Safe Environment Free from Accident Hazards
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, as evidenced by two separate incidents involving two residents. In one case, a resident's bed was observed to have a six-inch gap between the footboard and the end of the mattress, which posed a risk for entrapment. The Registered Nurse of Clinical Operations confirmed the presence of the gap, and no gap filler was found in the room. The Director of Plan Maintenance measured the gap and acknowledged that gap fillers are typically used when beds are extended for taller residents, but could not confirm when the bed had been extended for this resident. In another instance, a resident was found lying in bed with an aerosol spray can of Clorox Fabric Sanitizer on the overbed table. Although the table was not within the immediate reach of the resident, the product could have been accessed by other residents entering the room. The facility's RN stated that the product was not used by the facility and was likely brought in by the resident's family. The safety data sheet for the product indicated it could cause respiratory, eye, and skin irritation, as well as gastrointestinal symptoms if ingested. The resident's assessment showed they were rarely understood and lacked capacity to make medical decisions. There was no documentation that the family had been notified about prohibited products.