Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who had multiple complex medical conditions including atrial fibrillation, COPD, and respiratory failure, was assessed as requiring supervision while smoking, the use of a smoking apron, and for his lighter to be kept at the nurses' station. Despite these documented requirements, the resident was observed smoking independently in the outdoor courtyard without staff supervision, not wearing a smoking apron, and keeping his cigarettes and lighter in his wheelchair pouch. The resident confirmed he had not been supervised while smoking for some time, did not use the apron, and always kept his smoking supplies with him, contrary to the care plan and facility policy. Another resident, who had moderate cognitive impairment and significant mobility limitations due to multiple trauma, stroke, and multiple sclerosis, left the facility premises with a friend without notifying staff or signing out, as required by facility protocol. Staff discovered the resident was missing when his wheelchair was found outside by the drive, prompting a facility-wide search and calls to the resident's family and friend. The resident later returned and stated he was unaware of the need to inform staff or sign out when leaving, as this was not required in his previous assisted living setting. The resident's family also confirmed being contacted by the facility during the search. Both incidents demonstrate lapses in the facility's adherence to its own policies and care plans regarding resident safety and supervision. In the first case, the resident's smoking was not properly supervised according to the documented assessment and policy, and in the second case, the resident was able to leave the facility unsupervised despite his cognitive and physical impairments, and without following the required sign-out procedure. These failures resulted in the residents not receiving the level of supervision and environmental safety required to prevent accidents.