Failure to Maintain Safe Environment and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. One resident, who had diagnoses including cerebral palsy, diabetes, and paraplegia, was observed using a wheelchair with both armrest covers peeled off, exposing rough and uneven surfaces. The resident reported the damage had been present for six months, and the Director of Rehabilitation Services confirmed that such damage could cause skin abrasions or tears. The resident's care plan identified a risk for skin integrity impairment and required elimination of potential causative factors, but the wheelchair armrests were not maintained in good condition as per facility policy. Two other residents, both with significant mobility impairments and a history of falls, did not have floor mats in place as ordered for injury prevention. One resident with Parkinson's disease and hemiplegia had a physician's order and care plan intervention for a right-side floor mat to prevent injury from falls, but no mat was present during multiple observations. Nursing staff and the Assistant Director of Nursing confirmed the absence of the mat and acknowledged it was required by the care plan and physician order. The second resident, with muscle weakness, hemiplegia, and a recent history of falls and fractures, also had a care plan and physician order for a floor mat on the left side of the bed. Observations on consecutive days confirmed the absence of the mat, and both the resident and staff verified that the intervention had not been implemented since admission. The DON acknowledged that the lack of a floor mat was not in accordance with the care plan and physician order, and that the facility's fall prevention policy was not followed.