Failure to Supervise Residents and Monitor Elopement Devices
Penalty
Summary
The facility failed to implement effective safety measures by not supervising residents during mealtime on the Third Floor. During a dining room observation, it was noted that eight residents were left unsupervised while eating lunch. Interviews with staff, including two LPNs, confirmed that supervision was required but not provided. The Nursing Home Administrator acknowledged the lack of supervision during mealtime, which is a failure to ensure the resident environment remains as free of accident hazards as possible. Additionally, the facility did not adequately monitor elopement prevention devices for a resident diagnosed with dementia, hyperlipidemia, and anxiety. The resident had a history of wandering and exit-seeking behavior, and a physician's order required daily checks of an electronic bracelet designed to alert staff if the resident left a safe area. The facility failed to document checks of the bracelet's function and placement on multiple occasions, as confirmed by the Director of Nursing. This oversight indicates a failure to provide adequate supervision and assistance devices to prevent accidents.
Plan Of Correction
Nursing is currently documenting checking placement and function for Resident #82's electronic bracelet. There were no other concerns identified regarding supervision during meal service during survey. To identify other residents that have the potential to be affected, the Director of Nursing (DON)/designee reviewed current residents with electronic bracelets to ensure documentation occurring for checking placement and function of electronic bracelet. Corrections will be made as needed. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated staff on the supervision during meal service and ensuring residents receive adequate monitoring of elopement devices (checking placement and function). To monitor and maintain ongoing compliance, the DON/designee will audit meal service for supervision for meals and electronic bracelets for documentation of placement and function weekly x4 then monthly x 2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.