Failure to Prevent Environmental Hazards and Timely Document Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision, as evidenced by issues involving two residents. For one resident with respiratory failure and diabetes, surveyors observed an extension cord in the room with the bed electrical cord, wheelchair electrical cord, and cellphone electrical cord all plugged into it. The resident stated she had purchased the extension cord herself and used it for these devices. The Maintenance Director stated that medical devices should not have been plugged into an extension cord in the room, and the Executive Director stated he was unaware the resident had an extension cord and that medical devices should not have been plugged into it. The State Operations Manual, Appendix PP, specifies that extension cords should not be used in place of adequate wiring and should be connected to only one device to prevent overloading. The deficiency also includes the facility’s failure to timely document and report a fall for another resident with hemiplegia and hemiparesis following a stroke. Therapy notes on multiple dates documented the resident’s reports of left shoulder pain due to a fall from his wheelchair, including mention of hearing a pop at the time of the fall. A physician progress note later documented increased left shoulder pain since a fall, and an x-ray report showed osteoporosis, mild to moderate shoulder osteoarthritis, and a likely acute distal clavicular fracture. Subsequent physician documentation referenced the need for further imaging and screening for osteoporosis. The facility’s later investigation determined that the resident had fallen out of his wheelchair onto the grass in front of the facility, was assessed by an LPN, and assisted back into the wheelchair. The investigation documented that the LPN instructed another LPN to enter the fall into the Risk Management system on the day of the incident, but this was not done because the second LPN forgot, and the Executive Director stated he did not learn of the fall until weeks later when the investigation was initiated.
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