Hazardous bedside storage and lack of smoking safety assessments: Surveyors observed aerosol products and a cigarette lighter stored at a resident’s bedside, with the same items still present later. Two residents who smoked had histories of stroke with left-sided hemiplegia and BIMS scores of 15, but the record lacked evidence of a completed safe smoking assessment for either resident. One resident had burn holes on a wheelchair cushion, cigarettes and a lighter kept in a nightstand drawer that was not used, and the other had cigarettes observed on a desk and nightstand with no smoking-related interventions in the care plan.
A resident sustained a rib fracture after a mechanical lift transfer from a wheelchair to bed went wrong. Two CNAs were assisting when the resident’s legs were positioned on either side of the lift boom, the lift was rotated to align with the bed, and the lift tipped, causing the resident to be guided to the floor; the lift bar contacted the resident’s head and the resident reported chest contact. ED CT imaging showed a small, nondisplaced anterior right 8th rib fracture.
A resident with Parkinson’s disease and obesity, documented as a 2-assist for bed mobility and dependent for personal hygiene/oral care, was being washed by one CNA alone when the resident began sliding off the bed. The CNA could not stop the descent, called for help, and the resident was lowered to the floor; later ED documentation showed bilateral comminuted femur fractures. Interviews confirmed the resident required two staff for care and that the care was not provided as documented.
A facility failed to keep the environment free of accident hazards when a patient lift had a broken safety clip and a bottle of Clorox Urine Remover was left unsecured in a resident room. The facility also failed to complete required motorized wheelchair safety screens for a resident with a history of unsafe power chair use, including an incident where the resident pushed another resident and ran over that resident’s foot.
Accident Hazard From Loose Commode and Incomplete Smoking Assessment: A resident's commode had very loose bilateral arms that would not stay in place and was observed as an accident hazard by surveyors and confirmed by the DON and DES. The resident said the commode was needed because the resident could not get into the bathroom and had been asking for a new one for quite a while. In addition, an RN smoking evaluation for another resident lacked documentation showing whether the resident could smoke independently or needed supervision, which the DON confirmed.
Unsafe Chemical Storage in Laundry Room: Surveyors observed the clean side laundry room door ajar and not locked, allowing access to hazardous chemicals including bleach, disinfectant, odor eliminator, wipes, and an unlabeled spray bottle. A laundry aide confirmed the door does not always shut, and the Administrator acknowledged the chemicals were not stored safely to safeguard residents who are confused and ambulate in wheelchairs.
A resident with Alzheimer’s disease, dementia with psychosis, severe cognitive impairment (BIMS 8/15), history of falls, and documented confusion and hallucinations was placed in a room directly across from an unsecured exit door, despite staff concerns and family reports of wandering-type behaviors. The resident was assessed as zero risk for elopement, and no elopement policy or Roam Alert was implemented even after earlier wandering and a stairwell incident. Video showed the resident repeatedly wandering the hall, exiting through the unsecured door once and returning unnoticed, then exiting again without staff awareness, passing through to a locked courtyard where reentry was not possible. Staff later discovered the resident missing and found the resident face down on snow-covered ground in the courtyard, inadequately dressed for the cold, leading to an Immediate Jeopardy determination for failure to prevent avoidable accidents and environmental hazards.
A facility failed to keep the resident environment free of accident hazards when two 8.8-ounce spray bottles of Febreze Air Effects Gain Original were observed sitting on a shelf at the foot of a resident's bed. An LPN confirmed that confused residents moved around the unit and could enter rooms and access hazardous chemicals.
An EZ Sit to Stand lift was observed missing both safety pins, and an RN confirmed the issue before the lift was removed from the unit. In a separate observation, an unsecured container of CaviWipes was found on a med cart with no staff in sight; an MTA confirmed the wipes should have been secured because vulnerable and ambulatory residents were on the unit.
Damaged doors and protective coverings created accident hazards in common areas and on the Cove Unit. A small sitting room door had a broken protector sticking out and sharp, and a wooden double door in the lobby had a gouge with missing wood and sharp edges; an LPN and the Administrator both confirmed the observations.
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