Failure to Prevent Accident Hazards, Falls, and Inaccessible Call Light
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and assistive devices for three residents. One resident who smoked was observed with cigarettes and a lighter at bedside, despite a smoking assessment documenting safety concerns such as burns to skin, clothing, furniture, and dropping ashes on self, with a recommendation to smoke only with supervision. Facility policy required smoking materials to be maintained by designated staff, and both an LVN and the ADON stated residents were not allowed to keep smoking paraphernalia at bedside without an IDT meeting, physician notification, and care plan in place. There was no documented evidence that such an IDT meeting, physician notification, or care plan had been completed for this resident, and staff were unaware the resident had cigarettes and a lighter at bedside. Another deficiency involved a resident at risk for falls who did not receive adequate supervision and effective fall prevention interventions. This resident had diagnoses including abnormalities of gait and mobility, was assessed as lacking capacity to understand and make decisions, and was identified as at risk for falls. The MDS indicated the resident required supervision or touching assistance for transfers. The resident experienced an unwitnessed fall while attempting to transfer, resulting in facial injuries and hospital transfer. CNAs reported the resident had a history of attempting to transfer independently from wheelchair to bed or toilet, that staff were aware of this behavior, and that one CNA had observed such behavior previously but did not report it to the licensed nurse. The ADON stated CNAs were expected to report unsupervised transfer attempts so that a fall risk assessment and care plan updates could be completed, but the care plan contained no revisions addressing the resident’s behavior of attempting to transfer independently prior to the fall. A third deficiency involved a resident at risk for falls whose call light was not within reach. The resident, who had diagnoses including frequent falls and lacked capacity to understand and make decisions, was heard yelling from her room and was found in bed with the call light hanging to the side of the bed and not within reach. The resident stated she wanted her bedside table moved and was unable to locate her call light. The resident’s care plan documented that the call light should be placed within reach and that the resident needed a prompt response to all requests for assistance. During observation and interview, an LVN confirmed the call light was not within reach and acknowledged that if the call light was not within reach, the resident would be unable to request assistance, including during an emergency. Facility policy required staff to ensure the call light is within reach of the resident and secured as needed.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.