Failure to Prevent Lift-Related Fall and Enforce Smoking Safety Interventions
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and follow safety interventions related to mechanical lift use and supervised smoking. One resident with a right foot fracture, morbid obesity, back pain, diabetes mellitus type 2, and bipolar disorder was care planned as a total mechanical lift transfer and identified as at risk for falls. While being transferred from bed to a stretcher for an orthopedic follow-up appointment, the mechanical lift lost balance while turning, tipped over, and the resident fell to the floor while still connected to the lift. A CNA witness confirmed that the lift tipped over during the transfer and that the resident had to be lifted from the floor. The facility’s mechanical lift and transfer policy stated that resident safety was a primary concern. The deficiency also includes failures to follow smoking safety interventions for two supervised smokers. One resident with COPD, respiratory failure, heart disease, and right-hand amputation was assessed as a supervised smoker requiring a smoking apron due to dexterity problems; however, during a smoking time, staff did not provide the required smoking apron, which was confirmed by both the resident and the CNA involved. Another resident with dementia, bilateral traumatic arm amputations with prostheses, COPD, and nicotine use was care planned and assessed to require adaptive equipment, one-on-one supervision, and a smoking apron. During an observed smoking period, this resident smoked without a smoking apron while a CNA distributed and lit cigarettes; ashes were seen falling onto the resident’s lap and upper thighs as he scraped the cigarette ashes off with his prosthesis. The CNA confirmed the resident did not use a smoking apron and stated she was unaware of anyone needing one, despite the facility’s Resident Smoking Guidelines defining and requiring smoking aprons for safety.
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.