Failure to Implement Safe Smoking and Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and adequate supervision to prevent accidents for three residents. One resident with chronic atrial fibrillation, COPD, and nicotine dependence, cognitively intact and requiring supervision for ADLs, had a physician’s order and care plan requiring use of a fire-retardant smoking apron when smoking. During observation in the designated smoking area, the resident was seen smoking without the required apron and had a cigarette burn hole on the left pant leg. A CNA confirmed the absence of the apron and stated she had previously informed a nurse that the resident needed a smoking apron. The DON later verified that both the physician’s order and care plan required the apron. A second resident, admitted with stroke, dementia, epilepsy, unsteadiness on feet, chronic kidney disease, and weakness, was cognitively intact, required supervision or touching assistance for transfers, and had two or more falls since admission. The resident had a physician’s order for a wheelchair pressure alarm with placement and function to be checked every shift, and the care plan identified fall risk with an intervention for a chair alarm. During observation, the resident self-propelled in a wheelchair and independently transferred to a bedside commode; although an alarm pad and speaker were present on the wheelchair, the alarm did not sound when the resident transferred. An LPN confirmed the alarm should have sounded, verified it was not disconnected or turned off, and that it did not function correctly. When assisting the resident back to the wheelchair, the LPN also found the left wheel lock was broken and did not lock. A third resident, admitted with Alzheimer’s disease, Parkinson’s, dementia, repeated falls, weakness, unsteadiness on feet, and a history of falling, had a physician’s order for a “call don’t fall” sign and was assessed as at risk for falls due to multiple falls in the last 90 days, cognitive behaviors, ambulation problems, and unsteady transfers. The care plan included interventions to analyze previous falls, place a “call don’t fall” sign in the room, and ensure the call light was within reach. A prior fall investigation documented that the resident had fallen while independently ambulating when the call light was not in reach, and a “call don’t fall” sign was added as a new intervention. On observation, the resident was sitting in a recliner near the hallway side of the room, with the call light clipped to the room divider curtain out of reach and no “call don’t fall” sign present. An LPN confirmed that fall-risk interventions include a “call don’t fall” sign and call light in reach, and verified both the absence of the sign and that the call light was out of reach, despite TAR documentation indicating the sign was in place.
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