Failure to Control Environmental Hazards for Resident With Known Finger-Wrapping Behavior
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards by allowing accessible call light cords and bed control cables for a resident with known behaviors of wrapping items around her fingers. The resident, who had aphasia following cerebral infarction, a history of gangrene on a finger from wrapping behavior prior to admission, and moderate cognitive impairment, was dependent for most activities of daily living. During observation, the resident was seen in a customized wheelchair with red discoloration and a darker red band around her left middle finger, and she nodded when asked if she had placed her finger in the tangled call light cord beside her bed. The resident’s bed was observed with tangled call light cords hanging on the inner side of the upper quarter bed side rail and coiled bed control cables hanging on the upper left side of the bed. Staff interviews confirmed prior knowledge of the resident’s behavior and the associated hazards. An LVN stated the resident could twist and wrap her fingers with the coiled bed control cables and tangled call light cords, and that these should be kept away from the resident because she was not capable of using them. CNAs reported being informed in a staff huddle that the resident liked to play with and tie things around her fingers, and at least two CNAs had personally observed the resident wrapping cords or gown strings and GT tubing around her fingers on previous occasions, but did not report these incidents to other staff. The DON acknowledged the resident’s prior history of gangrene from wrapping behavior, confirmed that tangled cords and cables were safety hazards for this resident, and noted that the resident’s care plan lacked any problem or interventions specific to her wrapping behavior, despite an existing generic risk-for-injury care plan. The facility’s policy on Safety and Supervision of Residents stated that the environment should be as free from accidental hazards as possible and that safety risks are to be identified through training, monitoring, and reporting, but this was not implemented for this resident’s known behavior.
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