Failure to Provide Adequate Supervision and Safe Medication Handling
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free of accident hazards for three residents, resulting in falls and unsafe medication handling. One resident with lumbar disc degeneration, movement disorder, and cardiomegaly was assessed as cognitively intact but required two-person assistance for transfers and supervision when toileting, and was identified as high risk for falls on the Morse Fall Scale. Despite this, a nurse aide transferred the resident alone to the bathroom commode, left her unsupervised, and instructed her to use the call light when finished. The aide left the bathroom to go to the nurse’s station, and upon returning a short time later, found the resident on the floor beside the commode after the resident had apparently attempted to manage independently. Another resident with acute respiratory failure, dementia, and anxiety was assessed as severely cognitively impaired and at high risk for falls on the Morse Fall Scale. The care plan identified fall risk related to gait and balance and required two staff for transfers between surfaces, but did not include specific interventions for supervision while in a common area or up in a chair. The resident was later found face down on the floor in front of a chair in the TV/common area after an unwitnessed fall from a Broda chair, with documented injuries including a swollen, bleeding nose, a new laceration over the right eyebrow, facial bruising, and right shoulder pain, and was diagnosed with a closed nasal fracture. Staff interviews revealed that some aides and nurses did not consistently review care plans, and one LPN reported not recalling training on assessing residents for fall risk prior to the incident. A third resident with severe cognitive impairment and not assessed to self-administer medications was observed seated in a wheelchair at her bedside table with a medication cup containing multiple crushed medications mixed in pudding and a spoon left unattended in front of her. The Medication Administration Record showed that several oral medications, including antihypertensives, aspirin, vitamin D, stool softener, urinary tract infection prophylaxis, beta-blocker, and acetaminophen, were documented as given that morning by a medication aide. The medication aide stated the unattended cup was from the previous night and admitted she had not removed it when she entered earlier to administer the morning medications. Facility policies required medications to remain under direct observation during administration or be secured, and required staff to observe residents consuming medications, but the unattended medication cup at the bedside demonstrated a failure to follow these policies and to ensure medications were not left accessible or unmonitored.
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.