Failure to Provide Adequate Supervision and Safe Environment for Residents
Penalty
Summary
The facility failed to minimize the risk of preventable accidents for two residents by not providing adequate supervision and not ensuring a safe environment. One resident with a history of wandering, hemiplegia, dementia, and poor safety awareness was repeatedly observed walking unaccompanied in hallways and between units without staff supervision. Despite being identified as high risk for falls and serious injuries, and care plan interventions calling for close supervision or frequent visual checks, the resident was seen wandering alone on multiple occasions. Staff interviews confirmed that the resident required more supervision to ensure safety, and that her wandering behavior was sometimes upsetting to other residents. Another resident, identified as a current smoker with mobility limitations due to right hip osteoarthritis, was observed using a designated smoking area that did not meet facility policy requirements for safety. The area was unpaved, uneven, and surrounded by flammable plants and brush. There was no fire extinguisher present, and a plastic trash can with a thin liner was located near the smoking area. The resident and staff were observed disposing of cigarette butts in the plastic trash can instead of the required fire-proof receptacle. The DON confirmed that this was not in accordance with facility policy, which mandates a fire extinguisher and proper disposal of smoking materials in a fire-proof receptacle. The facility's policies on accident hazards and supervision require individualized interventions and environmental modifications to reduce risks, as well as specific safety measures for residents who wander and for designated smoking areas. The observed practices did not align with these policies, resulting in increased risk of avoidable accidents and injuries for the residents involved.