Inadequate Supervision and Documentation Lead to Resident Incidents
Penalty
Summary
The facility failed to ensure the safety and adequate supervision of several residents, leading to incidents of elopement and falls. One resident, diagnosed with dementia, was found outside the facility by a CNA, indicating a lapse in supervision and documentation. The resident's medical record did not reflect the elopement incident, and the wandering assessment was inaccurately completed, failing to document the resident's behavior and history of wandering. Another resident with a history of falls and requiring assistance for daily activities was inaccurately assessed as a moderate fall risk upon admission. The care plan did not adequately address the resident's unsteady gait and history of falls, and there was a lack of documentation and intervention following a fall on January 21st. The facility's failure to update the care plan and accurately assess the resident's fall risk contributed to repeated falls. A third resident experienced a fall resulting in a wrist fracture, yet the facility's records did not accurately reflect the incident or the resident's fall risk. The fall risk assessment was inconsistent with the resident's condition and medication use, and there was a delay in conducting a physical therapy evaluation. Additionally, another resident's fall was not properly documented, and the neurological assessment provided was deemed false, as it included data recorded while the resident was in the emergency room.