Inadequate Supervision Leads to Resident Accidents
Penalty
Summary
The facility failed to provide adequate supervision for two residents, leading to accidents. Resident #2, who was admitted with diagnoses including major generalized wasting and reduced mobility, was found on the floor beside her bed by a staff member who failed to report the incident. The resident was later sent to the hospital for evaluation and was found to have sustained injuries. A risk evaluation indicated that Resident #2 was at high risk, yet the necessary supervision and interventions were not adequately implemented. Resident #3 was also found lying on the floor next to her bed in an unwitnessed incident. Despite being identified as high risk, the resident was left unsupervised in the common area and in her wheelchair next to her bed. The Director of Nursing acknowledged that residents with a high-risk score should be supervised while in common areas, but no interventions were put in place on the care plan after the incidents. This lack of supervision and failure to implement necessary interventions contributed to the accidents involving both residents.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance. 1. Risk evaluations completed for Resident #2 and Resident #3. Appropriate revisions were made to the care plans to reflect all current interventions. 2. Risk Evaluation completed for all residents currently residing in the facility by Care plans reviewed and revised as indicated for residents identified as at risk for to make certain interventions are documented for each and are reflected on the Kardex. 3. Regional Director of Clinical Services/Designee educated staff on Accidents and Supervision policy: Prevention in Long Term Care; and Resident Rights with emphasis on the development and implementation of a person-centered care plan. Licensed staff educated on Prevention Program and reviewing the Kardex for interventions. 4. Director of Clinical Services (Nursing)/Designee will review new admission records for initiation of Baseline Care Plan to make certain those identified to be at risk for have interventions/safety measures, five times a week x 4 weeks and once weekly x 8 weeks, then as needed as indicated. Director of Clinical Services/Designee will review records of residents who sustain to make certain documentation includes Change in Condition, Physician Notification, Responsible Party Notification, Care Plan Update with intervention and placement on Kardex five times a week x 2 weeks; three times a week x 8 weeks.