Failure to Prevent Accident Hazards and Inadequate Elopement Risk Assessment
Penalty
Summary
The facility failed to maintain a safe and functional environment for a resident with severe cognitive impairment and a known behavior of placing objects in his mouth. Despite documentation in the care plan and staff awareness of this behavior, the resident was observed with access to potentially hazardous items such as a perineal cleanser bottle and multiple disposable razors in his bedside drawer. On separate occasions, the resident was seen putting a cleanser bottle and a blanket in his mouth. Staff interviews confirmed that the resident was not permitted to keep such items within reach, and that frequent monitoring was necessary due to his behavior. Additionally, the facility did not properly evaluate another resident's risk for elopement. This resident, also with severe cognitive impairment and a history of confusion, was observed wandering the facility and attempting to enter other residents' rooms, requiring constant supervision by a sitter or CNA. Despite these behaviors, the resident's elopement risk assessments did not accurately reflect his risk level, and there was no care plan developed to address his risk of elopement. The DON acknowledged that the assessments were inaccurate and that a care plan should have been in place. Facility policies required the review of incidents and accidents for trends and individual vulnerabilities, as well as accurate and complete documentation. However, the observed deficiencies in supervision, environmental safety, and risk assessment for these residents demonstrated a failure to adhere to these policies, placing residents at increased risk for injury and accidents.