Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for multiple residents, resulting in several deficiencies. One resident with a history of cerebral infarction, severe vascular dementia with agitation, and memory deficit was involved in multiple incidents of verbal and physical aggression toward other residents. Despite documented care plans and psychiatric recommendations for one-to-one supervision, there were periods when the resident was left unsupervised, including overnight, and there was no physician order for the required supervision. Staff interviews confirmed inconsistent implementation of one-to-one supervision, and the facility lacked a formal policy or physician order protocol for such supervision. Another deficiency was observed when a syringe containing an unknown clear liquid was found unattended on a resident's dresser. The resident had diagnoses including bipolar disorder and PTSD. The presence of the syringe was confirmed by an LPN, who acknowledged it should not have been left in the room. The DON stated that staff are expected to ensure syringes are not left in resident rooms, indicating a lapse in following established safety protocols regarding hazardous items. A third incident involved a resident with vascular dementia and significant balance and gait issues who sustained a right hip fracture after an unwitnessed fall in the bathroom. The resident's care plan identified a high risk for falls and included interventions such as ensuring appropriate footwear and anticipating needs. However, the fall occurred when the resident was alone, and staff interviews indicated the resident was often in his room and did not like to leave for therapy. The fall was unwitnessed, and the resident was found on the floor by staff, resulting in hospitalization and surgery for a hip fracture.