Failure to Implement and Maintain Safety Interventions for Residents at Risk
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents, as evidenced by the lack of implementation of care-planned interventions and insufficient supervision. One resident, who was cognitively impaired and at high risk for falls due to Alzheimer's dementia and dependence on staff for mobility and transfers, had physician orders and a care plan specifying that fall mats should be placed on both sides of the bed. During an observation, it was found that the fall mat was not positioned on the right side of the bed as required, and staff confirmed this omission, attributing it to the difficulty of moving the bedside table. Another resident, also severely cognitively impaired and diagnosed with dementia, exhibited frequent wandering and aggressive behaviors, including physical altercations with other residents, entering other residents' rooms, and rummaging through their belongings. Nursing notes documented multiple incidents where this resident physically interacted with others, such as grabbing, pushing, and hitting, as well as attempts to take mobility devices and urinate in inappropriate places. Despite these ongoing behaviors and repeated altercations, there was no documented evidence that new interventions were implemented to address the resident's wandering or aggressive actions, aside from medication adjustments and a hospital admission for behavioral issues. Interviews with facility staff, including the DON, confirmed that required safety interventions were not consistently in place for the resident at risk for falls, and that no new strategies were documented or attempted to manage the aggressive resident's behaviors and prevent further resident-to-resident altercations. The facility's policies on fall prevention and dementia care outlined the need for individualized interventions and regular updates to care plans, but these were not fully executed for the residents involved.