Failure to Prevent Accidents and Implement Safety Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision or implement appropriate interventions for three residents. One resident with severe cognitive impairment and a history of wandering was able to elope from the facility. The care plan did not identify this resident as an elopement risk prior to the incident, and the elopement assessment did not reflect the resident's risk. After the elopement, the facility did not conduct a thorough investigation, as witness statements were not obtained, and there was uncertainty among staff about how the resident exited the building. Another resident, who was dependent for all activities of daily living and had moderate cognitive impairment, experienced multiple unwitnessed falls. The care plan included several interventions for fall prevention, such as bed and chair alarms and physical therapy (PT) evaluations. However, after a fall, the care plan was not updated, and there was no documentation that PT evaluated or treated the resident as ordered. The Director of Nursing confirmed that the resident should have been seen by rehab after the fall, but this did not occur. A third resident with epilepsy had a physician's order for seizure pads to be applied to both side rails while in bed. Observations on multiple occasions revealed that only one seizure pad was in place, with the other found on the dresser. The Unit Manager and DON both acknowledged that the resident should always have two seizure pads in place according to the physician's order, but this was not consistently done.