Failure to Assess and Supervise Residents' Community Safety Needs
Penalty
Summary
The facility failed to comprehensively assess the supervision needs of residents and develop individualized, person-centered interventions to identify and mitigate risks and hazards for residents when they were out in the community and upon their return. This deficiency was evident in the cases of three residents with significant cognitive and behavioral health issues, including moderate vascular dementia, substance use disorder, and alcoholism with impaired insight and judgment. The facility did not conduct or document comprehensive community safety assessments for these residents, nor did it establish clear prevention strategies or interventions to ensure their safety while outside the facility. One resident with moderate vascular dementia and a history of substance use, psychiatric hospitalizations, and cognitive impairment repeatedly left the facility unsupervised, often without signing out or notifying staff. On multiple occasions, this resident was missing for extended periods, sometimes over 17 hours, and was found by police or returned via ambulance after hospitalizations for medical issues such as COPD exacerbation. The resident's care plan lacked interventions related to community safety, and staff interviews revealed there was no systematic process to assess or address the resident's ability to be independent in the community. Another resident with a history of alcohol and opioid abuse, psychiatric diagnoses, and repeated falls was frequently found intoxicated both inside and outside the facility. This resident left the facility independently, often without using an assistive device, and was hospitalized multiple times for alcohol-related medical issues. The care plan did not address supervision needs or interventions for community safety, and there was no evidence of comprehensive assessment or monitoring for withdrawal symptoms, nor strategies to prevent or mitigate risks associated with the resident's behavior in the community or upon return. Staff interviews confirmed the absence of a clear process for assessing community safety or implementing individualized interventions for residents at risk.