Failure to Provide Adequate Supervision and Safe Environment for Residents
Penalty
Summary
The facility failed to ensure that two residents were provided with adequate supervision and a safe environment, resulting in accident hazards and actual harm to one resident. One resident with multiple complex diagnoses, including Parkinson's disease, traumatic brain injury, epilepsy, and mobility impairment, was identified as being at high risk for falls and required staff assistance for transfers and toileting. Despite a physical therapist's documented recommendation for 1:1 supervision due to repeated falls and a history of seizures, the facility did not implement this intervention or increase supervision. The resident experienced multiple unwitnessed falls, including one that resulted in a hip fracture while self-transferring from a wheelchair to bed. Documentation showed that the care plan was reviewed after each fall, but no new or enhanced interventions were put in place, and there was no evidence of staff education following the injury. Interviews with staff and administration confirmed that 1:1 supervision was not provided, and there was no documentation explaining why the recommended intervention was not implemented. Another deficiency was observed regarding the charging of a power wheelchair. A resident with multiple medical conditions, including diabetes, muscle weakness, and mild cognitive impairment, was found charging their motorized wheelchair in their room, rather than in a designated charging area behind a fire-safe door. The facility administrator acknowledged that the wheelchair should not have been charged in the resident's room and that there was no policy or procedure in place for power wheelchair charging. The lack of a policy and the improper charging location created a potential accident hazard within the resident's environment. The facility's own policies and clinical guidelines require the assessment of fall risk, implementation of appropriate interventions, and maintenance of a safe environment free from hazards. In both cases, the facility did not follow through with necessary actions to prevent accidents, either by failing to implement recommended supervision for a high-risk resident or by not having procedures in place to ensure safe charging of power wheelchairs. These failures resulted in actual harm to one resident and the presence of accident hazards for another.