Failure to Prevent Accidents, Unsafe Transfers, and Inadequate Smoking Safety
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident with a history of alcohol abuse, depression, anxiety, and moderate cognitive impairment, residing on a secured memory care unit, was assessed as a moderate elopement risk and had care plans and physician orders in place for frequent monitoring and a wander guard. Despite these interventions, the resident was able to elope by dislodging screws from a window, climbing out, and leaving the premises undetected. The resident was missing for several hours before being located at a family property four miles away. Observations after the incident revealed that the window in the resident's room could still be fully opened, and screws intended to prevent this were not in place. Another deficiency involved the unsafe and undignified transfer of a resident with Alzheimer's disease and severe cognitive impairment. A CNA was observed on video roughly transferring the resident from a wheelchair to a bed, lifting the resident under the arms and throwing the resident's legs onto the bed, resulting in an audible thump and a verbal expression of discomfort from the resident. The incident was reported by the resident's family, who had video evidence from a camera in the room. Although no injuries were found on assessment, the transfer was confirmed by the DON to be inappropriate and not in accordance with facility policy, which requires cooperative and safe transfer techniques. Additionally, the facility failed to implement proper smoking procedures for five residents. During a supervised smoking break, residents were observed without access to appropriate ashtrays, flicking ashes onto the ground, and handing lit cigarettes to staff for disposal. Cigarette butts were found scattered throughout the courtyard, including in non-combustible trash cans and among dried leaves. One resident with severe visual impairment and motor/dexterity concerns was not provided with a clothing protector during smoking, and the smoking safety assessment did not accurately reflect the resident's needs. Staff supervising the smoking break reported a lack of formal training on safe smoking protocols, and the facility's policy requiring fire blankets and approved ashtrays was not followed.