Failure to Maintain Hazard-Free Environment and Supervision to Prevent Accidents
Penalty
Summary
Staff failed to maintain a hazard-free environment for two residents by not responding promptly to bed alarms, not ensuring a Wander Guard alarm prevented unsupervised exit, and not maintaining a functioning bed alarm. One resident, with diagnoses including dementia, muscle weakness, and abnormal gait, was identified as high risk for falls and had a history of multiple falls. Despite physician orders and care plans requiring bed and wheelchair alarms, staff did not respond in a timely manner when the resident's bed alarm sounded, and multiple staff walked past the room without intervening. Additionally, a CNA was observed not knowing how to turn off the alarm, and interviews confirmed that staff were expected to respond immediately to such alarms to prevent falls. The same resident, who had a Wander Guard alarm to prevent unsupervised wandering, was observed entering the building through an emergency exit without staff supervision on two occasions. The Wander Guard and emergency exit alarms were both sounding, but staff did not respond or supervise the resident as required by physician orders and facility policy. The resident was able to be outside and re-enter the building without staff knowledge or intervention, and there were no cameras monitoring the area. Interviews with staff confirmed that the resident should have been supervised when outside due to the risk of elopement and accidents. A second resident, also with dementia and a history of falls, was observed in bed with a bed alarm monitor that was not functioning, as indicated by the lack of indicator lights. The resident's care plan and physician orders required a functioning bed alarm for safety, but the CNA was unsure if the alarm was working and did not know how to check it. The DON confirmed the alarm was not functioning and needed replacement, acknowledging that this posed a fall risk. Facility policy required implementation and monitoring of fall prevention interventions for residents at risk, which was not followed in this case.