Failure to Provide Adequate Supervision and Maintain a Safe Environment
Penalty
Summary
The facility failed to provide adequate supervision and assistance for a resident who was dependent on two staff members for bathing. Despite care plan interventions specifying the need for two staff during all care, only one staff member was present when the resident experienced a leg spasm, fell from the bed, and sustained fractures in both legs. The staff member involved reported that she routinely provided care alone, as no one would assist her, and the resident confirmed that only one staff member was present during the incident. Facility leadership and documentation confirmed the resident's dependence on staff for all care and the expectation that care plans be followed. The facility also failed to ensure the environment was free from accident hazards for several residents. One resident was found to have a plugged-in electric coffee pot in their room, which was against facility policy due to the risk of burns or fire. Staff and leadership interviews confirmed that such appliances were not permitted, and the presence of the coffee pot had not been reported or addressed. Another resident had expired and unlabeled medications, including a bottle of nasal spray and a cup of white cream, left at the bedside without proper orders or assessment for self-administration. Staff acknowledged that medications should not be left at the bedside and that the resident did not have orders for self-administration. Additionally, a resident's room was observed to have a loose metal chair rail with sharp edges and splintered wood, creating a physical hazard. The maintenance director and DON confirmed that these conditions had not been reported and posed a risk of injury. The facility's failure to maintain a safe environment and to follow policies regarding supervision, medication administration, and environmental hazards resulted in actual harm and placed multiple residents at risk.