Failure to Prevent Accidents Due to Inadequate Supervision and Implementation of Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent accidents for three residents. One resident, with moderate cognitive impairment and mobility issues, was able to leave the facility unsupervised and was returned by a community member after being found at a gas station over a mile away. Staff interviews revealed that the resident was last seen during a smoke break, and there was a lack of awareness among staff regarding the resident's whereabouts until he was brought back. Documentation showed that the resident was assessed as high risk for elopement, but interventions were limited to routine monitoring, and staff did not consistently monitor or supervise the resident as required. Another resident, with severe cognitive impairment and a history of stroke, was identified as high risk for elopement based on assessments and physician notes. However, the care plan did not include information or interventions related to this risk, and multiple staff members were unaware of any residents being high elopement risks. This lack of communication and failure to update care plans and inform staff resulted in inadequate supervision and increased the risk of elopement for this resident. A third resident, with a history of falls and moderate cognitive impairment, was not provided with required fall prevention interventions. Despite physician orders for a low bed and fall mat, the resident's bed was not in the lowest position and the fall mat was not in place at the time of a fall that resulted in a left hip fracture. Staff interviews confirmed that the interventions were not implemented, and the care plan did not specify these requirements. The incident report and staff statements indicated a lack of consistent implementation and monitoring of fall prevention measures for this resident.
Removal Plan
- Resident was discharged to a secured facility.
- All entrances to the facility have been key-pad locked and residents are not allowed out of the facility without an assigned staff member being with them.
- One resident who is high risk for elopement was placed on 1:1 monitoring until secure placement is located.
- All resident elopement assessments were completed, and high risk residents were identified.
- High risk resident's care plan was formulated and any resident care plans requiring updates were done.
- Administrator in-serviced department heads and facility staff on interventions for the identified high risk resident, including 1:1 monitoring, updated care plan, and Kardex update.
- Staff not available in person were contacted by phone and verbally in-serviced.
- Staff are informed that the administrator/designee will notify staff through the above measures and through an in-service if any other resident is deemed high risk for elopement.
- PRN, agency staff, and new hires will be educated on this process as they are assigned to work.
- Administrator will interview staff on their understanding and retention of education given to them on elopement and where to find information on residents at high risk for elopement.
- Regional Nurse will monitor new admission elopement assessments for high risk residents to validate that interventions are in place and communication is in the EMR system.
- Administrator will document this on an audit form.
- Regional nurse in-serviced the administrator and the director of nursing on reviewing any new admission elopement assessments to identify a resident scoring ten or more.
- Ensuring that any new staff are educated to the interventions of a resident deemed high-risk for elopement.
- Initial comprehension of education with the administrator and the DON was completed by questioning on understanding of the training by the regional nurse consultant.
- Regional nurse will document compliance using an audit form.
- Ad.Hoc QAPI meeting was completed with the IDT and the medical director to discuss this plan of removal.
- Resident's fall care plan interventions and Point of Care Kardex were reviewed and updated to reflect the resident's current condition.
- Regional Nurse Consultant/ADON reviewed the facility fall assessment report to identify residents at risk of falls and to validate that current interventions are in place on the resident care plan and Point of Care Kardex.
- RNC and the ADON reviewed all facility residents to validate that their fall interventions were care planned and that the Point of Care Kardex was updated to list the fall interventions.
- Audit was documented utilizing the PCC Fall Assessment score report.
- Additional residents were identified as at risk for falls. Each had a care plan developed with interventions added to their POC Kardex.
- RNC/administrator educated facility staff regarding where to find the information for fall interventions.
- Staff not receiving the initial education will receive it before starting their next assigned shift.
- Nurses were instructed to review the care plan, and CNAs were instructed to review the Point of Care Kardex.
- Interdisciplinary team were given a list of resident fall interventions by the RNC, to refer to while making rounds on their regularly assigned residents before the morning stand-up meeting and reporting any concerns during that meeting.
- IDT manager on duty will make rounds on the weekend to identify and immediately resolve concerns with fall interventions.
- Administrator verified the initial comprehension of staff training by questioning staff and documenting it on an audit form.
- Administrator and the RNC will document these tasks on a facility created audit form for record keeping purposes.
- RNC will review falls to ensure that the care plan is updated with a new intervention and that those interventions, if applicable, are carried over to the Point of Care Kardex.
- Any concerns will be corrected immediately and re-education given to the management team.
- Education understanding will be completed by the administrator by questioning the facility staff about where they can find the fall intervention information.
- RNC will complete education understanding with the management IDT by questioning them regarding IDT rounds and identifying problems with fall interventions specifically.
- Ad.Hoc QAPI meeting was held with the medical director and the IDT to discuss this plan of removal.