Failure to Provide Adequate Supervision and Accident Prevention for Resident with Dementia
Penalty
Summary
A resident with a diagnosis of dementia, severe cognitive impairment (BIMS score of zero), history of falls, muscle weakness, and other comorbidities was not provided with appropriate supervision and accident prevention services. The resident's care plan required that the call light be kept within reach and the door remain open for easier monitoring due to a history of unassisted walking and falls. However, observations revealed that the call light was found on the floor and not within the resident's reach, contrary to the care plan and facility policy. Staff interviews confirmed that call lights should always be accessible to residents with dementia and that such residents require frequent monitoring. Additionally, an incident occurred in which the resident was found in a common area with another resident who was observed groping her breast. Both residents were immediately separated, and neither recalled the incident when interviewed. The facility's documentation and staff statements indicated that the resident with dementia was severely impaired and unable to understand or communicate effectively, further emphasizing the need for close supervision. The failure to ensure the resident's call light was accessible and to provide adequate supervision placed the resident at risk for preventable accidents and incidents.