Failure to Prevent Ingestion Incidents, Maintain Fall Interventions, and Secure Hazardous Chemicals
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when a resident with a known history of pica and ingesting foreign objects repeatedly swallowed hazardous items without timely, targeted interventions in place. The resident was admitted with diagnoses including pica, borderline personality disorder, bipolar disorder, morbid obesity, and conversion disorder, and the facility was aware upon admission that she had a behavior of swallowing foreign objects at a sister facility. Despite this, the care plan addressing her behavior of swallowing batteries and other foreign objects was not initiated until early February, after three separate incidents in which she swallowed a thumb tack and multiple batteries, each requiring EMS transport and hospital evaluation or treatment. Facility leadership, including the COO, Administrator, and DON, confirmed that no follow-up investigations were completed to determine root causes or to develop interventions to prevent recurrence of these ingestion incidents, contrary to facility policies on safety, supervision, and incident investigations. A second deficiency involved failure to implement and maintain fall-prevention interventions for another resident with impaired cognition and a documented risk for falls. This resident had physician orders for Dycem to the wheelchair every shift and a fall care plan that included interventions such as placing the bed against the wall, keeping the bed in the lowest position, using floor mats beside the bed when the resident was in bed, and applying Dycem above and below the wheelchair cushion. During multiple observations, the resident was seen in bed without fall mats and with a wheelchair lacking Dycem above or below the cushion. A CNA, an RN, and the DON each confirmed that the resident did not have the ordered Dycem in place and that the care-planned fall interventions, including the floor mat, were not being implemented as specified. A third deficiency concerned unsecured hazardous chemicals accessible in an unlocked janitor’s closet on a resident hall. On two separate observations, the janitor’s closet on the 100 hall was found unlocked and containing three containers of concentrated sanitizing fabric refresher with warning labels indicating the product was corrosive, could cause irreversible eye damage, and could be harmful if absorbed through the skin. Staff, including a CNA, an LPN, an RN, and the Administrator, confirmed that the closet was unlocked and that it should have been locked when unattended. The Administrator further acknowledged concern because several facility-identified residents on that hall were cognitively impaired and independently mobile, making the unsecured chemicals a particular hazard under the facility’s own safety expectations.
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