Failure to Provide Adequate Supervision and Safe Environment Resulting in Resident Injuries
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision for two residents, resulting in preventable injuries. For one resident with Huntington's Disease and dementia, staff did not implement care plan interventions designed to reduce self-injurious behavior, such as anticipating needs and providing positive interaction. Additionally, staff failed to follow a physician's order for hourly monitoring of this resident's aggressive behavior. As a result, the resident sustained a self-inflicted scalp laceration and contusion after banging their head on a door, requiring hospital treatment. Subsequently, the same resident was involved in a physical altercation with a roommate, resulting in a nasal fracture, scalp hematoma, and severe facial pain, again necessitating hospital evaluation. Interviews with staff and review of records confirmed that the required hourly monitoring was not performed prior to these incidents, and staff were unaware of the monitoring order. Another resident, who was dependent on staff for eating due to severe cognitive impairment and upper extremity dysfunction, was left unsupervised with a lunch tray placed within reach. Despite being assessed as a moderate fall risk and requiring total assistance for eating, staff delivered the meal tray to the resident's room before being ready to assist. The resident attempted to reach for the tray independently and fell. Staff interviews confirmed that the tray should not have been delivered until assistance was available, and the DON acknowledged that the resident's confusion and inability to recognize hazards contributed to the fall. Facility policy required individualized supervision and environmental adjustments based on resident risk factors, including cognitive status and physical limitations. However, in both cases, staff failed to adhere to these requirements, resulting in injuries. Documentation and interviews revealed that staff were either unaware of or did not follow care plans and physician orders for supervision and monitoring, directly leading to the incidents described.
Plan Of Correction
F 689: FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CORRECTIVE ACTION Resident #37 was transferred to a General Acute Hospital on 3/2/25 for evaluation following self-inflicted injuries. On 3/4/25, the resident was placed under 1:1 sitter supervision for close monitoring. A healthcare provider ordered a helmet for the resident to wear while out of bed to prevent further self-inflicted harm. The IDT convened on (date) to review and update Resident #37's comprehensive care plan. On 3/24/2025, the DSD/Designee provided nursing staff with education on the importance of hourly monitoring for Resident #37, emphasizing behavioral observations and self-inflicted injuries. Resident #294 attempted to retrieve his lunch tray from the bedside table independently and was found on the floor on 3/5/25. The resident was assessed for injuries and placed under Close Observation and Care (COC) monitoring from 3/5/25 to 3/8/25. No injuries were noted from the fall. CORRECTIVE ACTION (CONTINUED) On 3/25/2025, the DON/Designee conducted an in-service training for licensed staff covering: - Comprehensive care planning for managing residents with self-inflicted injuries and aggressive behaviors - Abuse and neglect prevention and prohibition On 3/25/2025, the DSD/Designee provided CNAs with education on: - Abuse and neglect prevention and prohibition - Close supervision of residents during behavioral escalations and the immediate reporting of any behavioral changes to licensed staff - Safety and supervision during mealtimes, with a focus on residents requiring total assistance with eating OTHER RESIDENTS AFFECTED IDENTIFICATION All residents had the potential to be affected by the alleged deficient practice. From 3/21/25 to 3/25/25, licensed staff and the IDT conducted facility rounds to observe residents for any behaviors indicating self-inflicted injuries. No additional residents were observed with self-inflicted injuries. CORRECTIVE ACTION (CONTINUED) On 3/25/2025, the DON/Designee conducted an in-service training for licensed staff covering: - Comprehensive care planning for managing residents with self-inflicted injuries and aggressive behaviors - Abuse and neglect prevention and prohibition On 3/25/2025, the DSD/Designee provided CNAs with education on: - Abuse and neglect prevention and prohibition - Close supervision of residents during behavioral escalations and the immediate reporting of any behavioral changes to licensed staff - Safety and supervision during mealtimes, with a focus on residents requiring total assistance with eating OTHER RESIDENT AFFECTED (CONTINUED) On 3/28/25, the DSD/Designee monitored meal times to assess whether residents requiring total assistance with eating had their meal trays left on the bedside table before receiving assistance. No residents were observed experiencing the alleged deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/21/25, the Director of Nursing (DON) or designee conducted an additional in-service training session for licensed staff, focusing on the following topics: - Comprehensive care planning for residents with self-inflicted injuries and aggressive behaviors - Strategies for preventing and prohibiting abuse and neglect - Licensed staff rounds during mealtimes to ensure resident safety and supervision From 3/21/25 to 3/25/25, the Director of Staff Development (DSD) or designee provided training to CNA staff, which included: - Close supervision during behavioral escalations, along with immediate reporting of concerns to licensed staff - Accurate documentation for residents requiring close monitoring - Safety and supervision during mealtimes, specifically for residents who need total assistance with eating On 3/29/25, facility will initiate a hallway monitoring program where a monitoring aide will do rounds every two hours to identify residents with potential escalating or self-inflicting injuries behaviors. Findings will be logged on a Hallway Monitor Form and will be reported and addressed accordingly. As part of new hire orientation and annual performance evaluation, the DSD/Designee shall provide ongoing staff training and competency development in safety, supervision, and abuse prevention. PERFORMANCE MONITORING The safety committee will perform monthly audits of behavioral incident reports, staff training compliance, and the effectiveness of the hallway monitor program. Findings will be received during monthly safety QAPI meetings, where necessary adjustments to training and monitoring programs will be made based on recommendations. The Administrator/Designee will oversee the continued effectiveness of these systemic interventions and allocate additional resources as needed.