Failure to Supervise Resident Outside Secured Dementia Unit
Penalty
Summary
Staff failed to provide adequate supervision for a resident with moderate cognitive impairment and a history of Alzheimer's disease, non-Alzheimer's dementia, and diabetes, who resided on a secured dementia unit. On multiple occasions, the resident was observed sitting in the dining room outside the locked unit without any staff present, despite being at moderate risk for wandering according to a recent assessment. There was an exit door located approximately ten feet from where the resident was seated, and no staff were observed monitoring the area during this time. Further observations revealed that dietary staff were unable to access the locked unit and left the area without ensuring supervision for the resident. Later, the resident was able to re-enter the dementia unit only when visitors held the door open for her. Interviews confirmed that the resident should have been supervised when off the secured unit, but no staff were present. The facility was unable to provide a policy specifically related to resident supervision, and the only policy provided addressed incident and accident reporting.