Failure to Prevent Resident Access to Hazardous Equipment During Activity
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards for a resident with a history of PTSD, depression, agitation, and prior self-harm ideation. The resident, who had been recently admitted with diagnoses including Parkinson's disease with dyskinesia and PTSD, had documented behavioral issues such as agitation, paranoia, aggression toward staff, and delusional thinking. The care plan for this resident included monitoring for danger to self or others, identifying triggers, and using de-escalation techniques, but did not specifically address the risk associated with access to sharp objects during group activities. During a group baking activity, the resident requested removal of a hospital wrist band. The DON retrieved pointed desk scissors to remove the band and approached the resident. The resident grabbed the scissors from the DON, threatened self-harm, and pressed the open blades against their chest. Staff attempted to de-escalate the situation by asking for the scissors to be returned and removing other residents from the area, but were unsuccessful in calming the resident or retrieving the scissors. The incident escalated, requiring activation of a code grey, and the involvement of hospital security, police, and EMS. The event lasted over an hour, during which the resident continued to make threats of self-harm and resisted staff interventions. The police ultimately intervened to remove the scissors, and the resident was transported to the emergency department for evaluation and placed on suicide precautions. The facility's actions did not prevent the resident from accessing unsafe equipment, despite the resident's known behavioral risks and history of harm to self and others, resulting in a situation that placed the resident and others at risk.