Failure to Consistently Monitor and Implement Accident Prevention Interventions
Penalty
Summary
The facility failed to consistently monitor and address risk factors to minimize accident hazards for two residents. One resident, with diagnoses including dementia, substance abuse, and severe cognitive impairment (BIMS score of 5/15), was identified as high risk for elopement. Despite a care plan requiring one-on-one supervision during day and evening shifts and 15-minute checks at night, there was no documentation of the required 15-minute checks during the night shift. The resident exhibited ongoing exit-seeking behaviors, including being found in the parking lot attempting to leave the facility, and staff documented continued attempts to leave and poor safety awareness. Another resident, with a history of depression, diabetes, and bipolar disorder, was identified as a fall risk and had experienced multiple falls. The care plan included interventions such as a 'CALL DON'T FALL' sign and keeping the bed in the lowest position when unattended. Observations revealed that the sign was not posted in the resident's room during multiple visits, and the resident was found alone on a bed in the highest position while being partially dressed. The CNA assisting the resident was unfamiliar with the resident's fall risk status and left the resident unattended, contrary to the care plan interventions. Interviews with staff confirmed lapses in following care plan interventions for both residents. The Director of Nursing Services acknowledged that the required monitoring and documentation for the resident at risk of elopement were not completed as expected. Similarly, staff confirmed that the fall prevention interventions for the other resident were not consistently implemented, and the absence of the required signage and supervision did not meet facility expectations.