Failure to Prevent Accidents Through Adequate Supervision and Hazard Control
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement interventions to prevent accidents for multiple residents. One resident with dysphagia, hemiplegia, vascular dementia, and a care plan identifying a swallowing problem and risk for choking and aspiration was ordered a mechanical soft diet and required supervision while eating. The resident’s MDS documented that she coughed or choked during meals and had complaints of difficulty or pain with swallowing. A nurse’s progress note recorded that the resident reported a choking episode during a noon meal, with a short instance of labored breathing, and that her diet was downgraded and a referral to speech therapy was entered. Despite this, surveyors observed the resident eating lunch in bed in her room on two separate dates without staff supervision. The Director of Therapy confirmed that therapy had not been promptly notified of the choking episode and that prior speech therapy discharge recommendations included supervised dining and upright posture. Another deficiency involved a resident with cognitive impairment, dependence for all ADLs, inattention, disorganized thinking, and bowel and bladder incontinence who ingested an unknown amount of shampoo and body wash. An incident report documented that a CNA entered the room and observed the resident holding the bottle with the lid off, stating it tasted good and offering a drink. The CNA removed and discarded the bottle and notified an LPN. The incident report and staff interviews indicated that the resident subsequently vomited, developed diarrhea, and had decreased oxygen saturation with abnormal lung sounds, leading to transfer to the ER. The manufacturer’s safety data sheet for the product specified it was for external use only and to consult a physician if ingested. The DON acknowledged that the shampoo/body wash should not have been left where the resident could reach and drink it. A third deficiency concerned a resident with dementia, osteoporosis, osteoarthritis, severely impaired cognition, a history of falls, and a high fall risk score who resided on the memory care unit. A fall investigation documented that the resident had an unwitnessed fall and was found on the ground at the doorway to a central bathroom. The investigation and subsequent interview with the Dementia Unit Director indicated that staff had propped the central bathroom door open, allowing the resident to access the bathroom independently. The central bathroom was observed with a keypad lock, and the Dementia Unit Director stated the door was supposed to remain shut and locked at all times, with residents only accessing the bathroom under staff supervision. This sequence of events showed that the door was not maintained in the required locked state, contributing to the resident’s unwitnessed fall.
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