Failure to Monitor Wanderguard, Enforce Smoking Policy, and Supervise Dining Room
Penalty
Summary
The facility failed to implement appropriate monitoring and supervision in several areas, resulting in deficiencies related to accident hazards and resident safety. For one resident with moderate cognitive impairment and a history of elopement, the facility did not provide clear or consistent procedures for monitoring the function and placement of a Wanderguard device. Staff were unclear on how to check the device's function, and documentation lacked specific instructions. The care plan and facility policies did not provide adequate guidance, and the manufacturer's manual was not available. There was also a lapse in interdisciplinary team review documentation for residents at risk of elopement. Another deficiency involved a resident who was permitted to store and use e-cigarettes independently. Despite a care plan and assessment indicating the resident was aware of the rules, the resident was observed using an e-cigarette in her room on multiple occasions, contrary to facility policy requiring use only in designated areas. The resident kept e-cigarettes on her bedside table and admitted to using them indoors due to difficulty moving, indicating a lack of effective monitoring and enforcement of the smoking policy. Additionally, the facility failed to provide adequate supervision in the dining room for a resident with a history of dysphagia and pocketing food, who required a modified diet. The resident was repeatedly observed eating alone without staff present, including while consuming foods not properly prepared according to dietary orders. Staff interviews confirmed that supervision was expected for residents with altered diets due to choking risk, and the facility's policy required dining room supervision during meals, which was not consistently provided.