Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for four of eight sampled residents. For one resident with a history of falls and multiple diagnoses including acute respiratory failure, depression, schizophrenia, and generalized muscle weakness, the fall risk assessment was not accurately completed. Despite documentation of a recent fall and reported pain, the fall risk evaluation did not reflect this incident, leading to a lack of appropriate identification and intervention for fall risk as outlined in the facility's policies. Another resident with severely impaired cognition and chronic medical conditions was found to have an open container of disinfectant wipes left unattended and within reach on their tray table. Staff acknowledged that it was unsafe for this resident to have access to chemicals, and facility policy prohibits residents from having flammable or unsafe chemicals at the bedside. The presence of the disinfectant wipes posed a risk of accidental poisoning, especially given the resident's cognitive impairment. Additionally, two residents were found in possession of lighters and cigarettes, contrary to the facility's smoking policy, which requires all smoking materials to be stored in locked areas and prohibits residents from carrying such items. Staff interviews and documentation revealed that the smoking risk assessments for these residents were unclear and did not specify whether they required supervision while smoking. This lack of clarity led to confusion among staff regarding the necessary safety interventions and resulted in residents possessing smoking materials unsupervised, increasing the risk of fire hazards.