Inadequate Supervision and Maintenance Lead to Resident Incidents
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent accidents for two residents, leading to incidents involving elevator doors and access to a housekeeping closet. One resident, with a history of Alzheimer's Disease and right hip surgery, experienced two separate incidents where they were bumped by elevator doors, causing pain and discomfort to their right hip. Despite the resident's severe cognitive impairment and history of hip replacement, the facility did not ensure that the elevator sensors were functioning properly or that the incidents were promptly reported to the Director of Support Services for maintenance intervention. Another resident, with severe dementia and a history of wandering behaviors, was found inside a housekeeping closet due to a malfunctioning door striker plate. The resident, who was at high risk for elopement, was able to access the closet because the door could not close and lock properly. This incident occurred despite the resident's known wandering behaviors and the facility's policy to maintain a safe environment free from accident hazards. The facility's failure to maintain a safe environment and provide adequate supervision resulted in these incidents. The lack of communication and timely reporting of the elevator incidents to the appropriate maintenance personnel further contributed to the deficiency. Additionally, the unsecured housekeeping closet posed a significant risk to the resident with wandering behaviors, highlighting the need for proper maintenance and monitoring of facility areas to prevent similar occurrences.
Plan Of Correction
Plan of Correction: Approved February 11, 2025 F689: Free of Accidents, Hazards, Supervision, Devices I. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 had a pain assessment completed on 1/31/25 which indicated he did not have any pain. Resident #1 receives a pain screen completed every shift and has PRN APAP ordered that can be administered if needed. Resident #3 is non-ambulatory, requires extensive assistance from staff for ADL care/mobility (since last readmission on 12/17/24), and is no longer an elopement risk. His elopement assessment was updated on 1/31/25, along with his comprehensive care plan to reflect the changes in his medical status and low elopement risk. II. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the same deficient practice. Specific to resident #1, a work call was placed to Otis to have the elevator sensors inspected and cleaned, which was completed on 1/15/2025. House-wide education is in progress for all staff on reporting accidents and incidents through the appropriate chain of command, ensuring notification is made to the highest-level supervisor in the facility. Nursing Supervisors have been re-educated to immediately notify the Director of Support Services, or designee, via phone and email if an accident/incident occurs involving equipment that is not maintained by nursing. Specific to resident #3, all locked housekeeping closet doors have been checked, with no other striker plates found to be loose or otherwise malfunctioning, which could lead to recurrence. III. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? Routine maintenance/cleaning of the elevator sensors have been added to the Otis monthly preventative maintenance schedule. Incident and Accident Reports (I&As) are discussed the business day following the occurrence during the Interdisciplinary Team (IDT) morning meeting/clinical meeting. This ensures that follow-up has been communicated and completed. The Director of Nursing Services will complete an audit weekly for 12 weeks of all I&As to ensure no follow-up is omitted or missed during the IDT's review. Results will be presented to the QAPI committee monthly. The Director of Support Services, or designee will conduct audits twice daily to ensure locked housekeeping closets are secure and no other striker plates were loose, malfunctioning, or presented danger to residents. These audits will be completed for a period of at least 90 days post incident, seven days a week. Results will be presented to the QAPI committee monthly. Education is in progress with all nursing staff on Incident & Accident notification process for significant occurrences. This training will also be included in new care member orientation for all new staff. IV. How will corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? Results of the locked housekeeping door audit and the I&A audit are given to the Director of Support Services and Director of Nursing Services, respectively, for review, and are also presented to the QAPI committee monthly. The QAPI committee will determine when substantial compliance has been achieved, and when the audits can be discontinued, frequency changed, or if they should continue as currently scheduled. V. The date for correction and the title of the person responsible for correction of each deficiency? Date Certain - 3/17/2025 Person Responsible - Director of Support Services