F0689

E

Unsecured Medications, Inadequate Fall Prevention, and Unrepaired Door Hazard

Dublin, Ohio Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe, hazard‑free, and homelike environment, including improper medication security and supervision, delayed and incomplete fall prevention interventions, and failure to address a known door hazard. For one cognitively intact resident who was dependent on staff for medication administration but had an order to self‑administer only Promethazine under nurse supervision, surveyors observed multiple medications in his room. These included ordered medications such as Promethazine, allergy sprays, asthma inhalers, topical creams, and ammonium lactate, as well as additional inhalers (Symbicort and Breo Ellipta) for which there were no active physician orders. Some medications were on the bedside table and others were in a hospital return bag and backpack. The resident confirmed he kept medications in his room, including medications without current orders, and the Administrator acknowledged that only Promethazine was ordered for supervised self‑administration. In a separate instance, another cognitively intact resident who was dependent on staff for medication administration was found with a cup containing six morning medications on his bedside table. The RN confirmed these were his scheduled medications and that he was unable to self‑administer, despite facility policies requiring medications to be administered only by licensed staff and stored in locked compartments.

The facility also failed to implement timely and adequate fall prevention interventions for residents at risk for falls. One cognitively intact resident, dependent on staff for medication administration and requiring supervision for several ADLs, experienced a fall from bed while reaching for an item on her bedside table, resulting in a skin tear to her right forehead. The fall occurred on a specific date but was not documented until a late entry note several days later, and the intervention to utilize arm rails was not initiated until the date of the late entry. The DON confirmed the facility did not identify or document the fall until that late entry and that the intervention was not put in place until that time. Another resident with severe cognitive impairment, high fall risk, extensive assistance needs, and a history of falls had multiple fall‑related interventions care planned, including bilateral fall mats and 1/2 side rails for maneuverability. This resident had two prior unwitnessed falls from bed, one with the resident partially on the floor with his arm trapped between the bed rail and frame and another with the resident found on his knees on the floor mat holding the bed rail, with pain and a skin tear documented. During observation, his bed was found raised and one fall mat was pushed almost completely under the bed, limiting its protective function. The RN confirmed the bed was not in the lowest position and that the mat’s placement would allow the resident to fall directly onto the floor, despite facility protocol to keep beds in the lowest position for safety.

Additionally, the facility did not adequately address an environmental hazard related to the main entrance door, which resulted in injury to a resident. A cognitively intact resident with COPD, diabetes, peripheral vascular disease, and absence of the right great toe reported that a wound to his left big toe occurred when the broken front door slammed on his toe. Progress notes documented a skin issue to the left big toe with treatment started, but there was no documentation in the incident/accident log or medical record describing the door‑related incident. An RN stated she had received communication that the resident’s toe was crushed in the front door when it was broken, and confirmed the lack of incident documentation. The Maintenance Director reported the front door was first reported broken on a specific date and was not repaired until several weeks later by an outside vendor, indicating the door remained in disrepair during the period when the resident’s toe was injured. These combined failures—unsecured and unauthorized medications in resident rooms, leaving medications at bedside for a resident unable to self‑administer, delayed and improperly implemented fall interventions, and prolonged failure to correct a known door hazard—demonstrate the facility’s noncompliance with its own policies on medication storage, homelike environment, and fall risk management.

This deficiency was investigated under Complaint Numbers 2669834 and 1350536 and affected five residents in a facility with a census of 65. The residents involved had varying levels of cognitive function and physical dependence, including severe dementia, high fall risk, and multiple chronic conditions such as heart failure, COPD, diabetes, and osteoarthritis. Facility policies reviewed by surveyors, including Medication Administration, Medication Labeling and Storage, Homelike Environment, and Falls and Fall Risk, Managing, required that medications be stored securely and administered only by licensed staff, that residents be provided a safe homelike environment, and that resident‑centered fall prevention interventions be implemented and adjusted based on risk factors and environmental hazards. The observations, interviews, and record reviews showed that these policies were not consistently followed in practice for the residents cited.