Unsecured Chemicals on Housekeeping Cart: A housekeeping cart was observed unlocked and unattended, and staff confirmed it should have been locked when not in direct view. Review of the carts found chemicals including Enzyme Treatment and Disinfectant Deodorant labeled keep out of reach of children, and the Housekeeping Supervisor stated all housekeeping carts were to be locked when not in view of a housekeeper.
Unsecured portable oxygen cylinders were observed free standing in two residents' rooms despite facility policy requiring E-tanks to be stored in an approved holding device or storage rack at all times. One resident had moderate cognitive impairment and both residents had orders for oxygen therapy; an LPN and the DON both stated the cylinders should not be left free standing in resident rooms.
A resident with COPD, lack of coordination, and anxiety disorder had a prior fall with a care plan intervention for nonskid strips at the bedside. The facility later failed to keep that intervention in place, and the resident was found on the floor beside the bed after hollering for help, resulting in a left hip fracture and surgical repair. Surveyors observed the nonskid strips were not at the bedside, and the DON, ADM, LPN, and RD confirmed they were missing.
A resident with dementia, seizure disorder, repeated falls, and high fall risk was care-planned for a low bed with brakes locked, a fall mat, and call light within reach, and was totally dependent on staff for transfers and bed positioning. Despite this, staff accounts indicated the bed was often kept at about waist height, and several staff reported not seeing a fall mat at the bedside. The resident was later found supine on the floor with her head and torso under the bed, the bed frame resting on her chest and head, and the corded bed remote under her back, requiring staff to raise the bed to remove her. A detective observed that a fall alert device on the bed was not plugged in and that the call light was tucked behind the nightstand, out of the resident’s reach, though it worked when tested. EMS and police documented compression marks on the resident’s torso and face consistent with the bed frame and piston. The facility’s own safety policy required implementation of interventions to reduce accident risks, but records showed no care-plan revision with additional bed-related safety measures after prior falls and no documentation that existing interventions were consistently implemented, leading surveyors to cite a deficiency for failure to prevent accidents and maintain a hazard-free environment.
Incomplete Smoking Assessments for Tobacco-Using Residents: The facility failed to complete smoking assessments with each quarterly or comprehensive MDS for several residents who used tobacco. Records showed that residents with diagnoses including HTN, AKF, dysphagia, epilepsy, heart disease, nicotine dependence, MDD, anxiety, COPD, and DM2 had prior smoking evaluations, but later quarterly MDS assessments either did not assess tobacco use or lacked updated smoking documentation. The DON stated smoking assessments should be completed on admit, quarterly, and with a change of condition.
Unsecured razors were found unattended on the back of a shared sink in the room of two cognitively intact residents. One resident had COPD, HF, depression, HTN, and antiplatelet therapy, while the other had DVT, pneumonia, malnutrition, asthma, and an apixaban order. Facility policy required sharps to be placed in appropriate containers at the point of use, and both the LPN and DON stated the razors should not have been left unsecured in the room.
A resident with Alzheimer's disease, moderate cognitive impairment, and an Eliquis order fell while being changed and hit her head, causing a forehead bruise/hematoma and a skin tear to the elbow. The SBAR note showed the provider was not notified at the time of the incident, and an LPN later stated she called the resident's son but did not notify the physician or NP. The NP learned of the fall later during facility rounding, noted the resident's head injury and hip pain, and sent the resident to the ED for further evaluation.
Hot water temperatures were not monitored in several resident bathrooms, with sink readings of 132 to 134 degrees F found in multiple occupied rooms. The facility had an Accident and Hazard Prevention Policy and a Maintenance Director role requiring regular safety inspections, but no documentation showed temperature monitoring for months before the survey. Interviews with the DON, ED/Maintenance Supervisor, and Administrator showed inconsistent understanding of how often checks were done, while several residents were dependent on staff for hygiene or did not routinely use their bathrooms.
A resident with COPD, HTN, and depression was observed in the designated smoking area with cigarettes and a lighter in his shirt pocket, and the Staffing Coordinator lit the cigarette with the lighter the resident carried. The resident was not wearing a smoking apron during the session, even though the smoking safety evaluation required supervision during smoking times and the care plan later included smoking apron use. Staff stated residents were not supposed to keep cigarettes or lighters on them, and the DON stated smoking should be care planned and residents should not have these items on their person.
A facility failed to keep the resident environment free from accident hazards when an unsecured E-tank was observed sitting on the floor in a shared room without an approved holding device or storage rack. The resident receiving O2 had COPD, acute respiratory failure, and pneumonia, and RN A and the DON both stated the cylinder should not be on the floor.
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