Failure to Maintain Accident-Free Environment and Implement Care Plan Interventions
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision to prevent accidents. The resident, who had diagnoses including Alzheimer's disease, dementia, hemiplegia, and hemiparesis, was dependent on staff for activities of daily living and was not interviewable. The care plan for this resident included specific interventions such as the use of non-slip material (Dycem) on the wheelchair and padding with black pool noodle on the sides and lower front bars of the wheelchair to prevent injury and maintain skin integrity. However, multiple observations by the surveyor over two days revealed that these interventions were not in place, as the resident was repeatedly seen without the required non-slip material and padding on the wheelchair, contrary to the care plan directives. Additionally, the resident sustained two separate skin tears. The first was identified during a body check, with no evidence that staff were interviewed to determine how the injury occurred or if staff had observed the resident picking at the area. The second skin tear occurred when the resident's arm came into contact with a sharp area on a shower chair. Although the chair was removed after the incident, there was no documentation of preventative measures to avoid recurrence. Maintenance staff confirmed that shower chairs were not routinely checked for hazards such as jagged edges, and the inspection process focused primarily on mechanical function rather than safety hazards. The facility's policy required that interventions be implemented for any incident causing or potentially causing injury, with appropriate measures to prevent recurrence. Despite this, the investigation into the resident's injuries lacked staff statements or evidence of a thorough inquiry into the causes. Furthermore, staff were observed to be unaware of the care plan requirements regarding the use of non-slip material and padding, and these interventions were not consistently implemented, as evidenced by repeated surveyor observations.