Failure to Provide Required Supervision and Assistance for Resident Ambulation
Penalty
Summary
A deficiency occurred when staff failed to provide the necessary supervision and assistance required for safe ambulation for a resident with severe cognitive impairment, dementia, a history of repeated falls, and wandering behaviors. The resident's care plan and physician's orders specified that ambulation should only occur with staff assistance due to high fall risk, impaired cognition, incontinence, and use of high-risk medications. Despite these documented needs and orders, the resident was repeatedly observed ambulating and wandering in the hallways and common areas without any staff assistance. Multiple staff members were present during these observations but did not intervene or provide the required assistance. Interviews with facility staff revealed a lack of awareness and adherence to the resident's ambulation orders. A certified medication aide incorrectly stated that the resident did not have ambulation orders and was allowed to ambulate freely, while a licensed nurse initially stated the resident could ambulate alone before confirming the existence of the assistance-only order. Administrative staff confirmed that staff were expected to follow provider orders and the resident care plan. The facility's own policy required supervision and interventions to minimize significant injuries, but these were not implemented for this resident, placing her at risk for falls and related injuries.