Failure to Ensure Resident Safety Leads to Immediate Jeopardy
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage the facility, resulting in an environment that was not free of accident hazards. This failure allowed a resident with a history of suicidal ideation to access hazardous materials, specifically a disposable razor, which the resident used to cut their wrist. The incident placed the resident at risk for serious injury and resulted in an Immediate Jeopardy situation. The resident involved was admitted to the facility with diagnoses of bipolar disorder with psychotic episodes, major depressive disorder, and generalized anxiety disorder. The resident's clinical records indicated a history of suicidal ideation, and the care plan included interventions such as assessing for suicidal ideations and removing potentially harmful objects from the resident's environment. Despite these measures, the resident was able to obtain a razor and harm themselves, highlighting a lapse in the facility's supervision and safety protocols. Interviews with staff revealed that there were significant oversights in the supervision and room searches conducted for the resident. A nurse aide assigned to 1:1 supervision did not conduct a thorough room sweep at the start of their shift, and hazardous items such as razors, a screwdriver, and scissors were found in the resident's room after the incident. Additionally, the nurse who initially searched the room did not thoroughly check all areas, leaving potentially dangerous items accessible to the resident. These lapses in protocol contributed to the resident's ability to harm themselves, underscoring the facility's failure to ensure a safe environment.
Plan Of Correction
NHA and DON have been re-educated on their job descriptions by the Regional Support Team. NHA and DON will have their job description reviewed with them on an annual basis. The Regional Director of Operations/Designee will oversee the ADMIN and Director of Nursing to monitor job performance. The RDO/Designee will meet with the ADMIN and DON weekly x4 weeks to ensure ongoing compliance.