Failure to Provide Adequate Supervision and Monitoring in Dining Areas
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for six residents who were identified as being at risk for falls and required staff oversight according to their care plans. On the morning of 04/26/2025, one resident was observed sitting alone in a wheelchair in the dining room without staff present, despite care plan instructions for frequent monitoring and supervision due to dementia and an unsteady gait. A CNA confirmed responsibility for the resident but stated she could not watch everyone and acknowledged the risk of falls or choking if residents were left unsupervised. The CNA assignment sheet indicated that no staff were scheduled to monitor the dining room until 9:00 AM, leaving a gap in supervision. Later that day, five additional residents, three of whom were in wheelchairs, were observed unsupervised in another dining room. Staff, including the DON and two CNAs, entered the room after the residents had been left unattended, with one CNA confirming it was her scheduled monitoring time and acknowledging the importance of supervision to prevent falls. The care plans for these residents documented risks for falls due to factors such as decreased safety awareness, impaired mobility, use of antidepressant medication, and need for assistance with activities of daily living. Facility policy emphasized the importance of resident supervision and safety, but staff assignments and observed practices did not ensure continuous monitoring as required.