Failure to Implement and Update Safety Interventions for Accident Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions for multiple residents, resulting in deficiencies related to accident hazards and prevention. One resident with severe cognitive impairment and a history of wandering and exit-seeking behaviors eloped from the facility. Despite this event and subsequent removal of his wander alert device on two occasions, the facility did not reassess his elopement risk or update interventions accordingly. Staff interviews revealed uncertainty about the effectiveness of 15-minute checks, and there was no documentation of additional exit-seeking assessments after the resident refused to wear the wander alert device. Another resident, who was dependent on staff for all activities of daily living and had a history of falls and seizures, was observed multiple times in bed without the required fall mat in place, despite this being a care-planned intervention. Several staff members entered or passed by the resident's room without ensuring the fall mat was present. Staff interviews indicated confusion about whether the fall mat was still an active intervention, and the intervention was not consistently documented or implemented as required by the care plan. A third resident with a history of falls and mild cognitive impairment experienced 14 falls in less than six months. The care plan was not consistently updated after each fall to reflect a review of the effectiveness of interventions or the addition of new interventions. Documentation of interdisciplinary team (IDT) reviews was often delayed or missing, and new interventions, such as staff education or equipment changes, were not always added to the care plan. There was also a lack of documentation to show that staff were following scheduled interventions, such as toileting programs, and that care plans were revised in response to changes in the resident's condition or fall risk.