Failure to Monitor Nighttime Visitation Allows Unauthorized Entry
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents, as required by its own policies and procedures. During the night shift, an unknown visitor was able to enter the facility through the main entrance without staff awareness or proper monitoring. The visitor subsequently entered the room shared by two residents, one of whom had moderate cognitive impairment and required supervision for activities of daily living and functional mobility. The facility's main entrance was observed to be locked, with a security camera and a doorbell in place, but no receptionist or staff was present at the front desk during the night shift. One resident involved had a history of hemiplegia and hemiparesis following a stroke, type 2 diabetes mellitus, and difficulty walking. This resident's care plan indicated impaired cognitive function and required reorientation and supervision as needed. The resident's progress notes documented that a female visitor, unknown to staff and the resident, was found in the room late at night. The visitor did not sign the visitor logbook, and staff were unaware of how she gained entry. The incident led to family members being notified and law enforcement being called to the facility. Interviews with staff and residents confirmed that the unknown visitor's presence was not detected until after she had already entered the residents' room. Staff acknowledged that visitors should not be present during the night shift without proper authorization and that the logbook was not signed. The facility's policies required the facility to be locked at night and for a system to be in place to allow only approved visitors, but these procedures were not effectively implemented, resulting in a breach of resident safety and supervision.