Failure to Prevent Accidents Due to Inadequate Supervision and Hazard Controls
Penalty
Summary
Multiple deficiencies were identified related to the facility's failure to ensure a safe environment free from accident hazards and to provide adequate supervision to prevent accidents. Several residents with cognitive impairments and high risk for elopement or wandering were not properly supervised or monitored. In one instance, a resident with severe cognitive impairment and a high elopement risk was able to exit the facility unsupervised due to malfunctioning wander guard systems and inadequate staff response to door alarms. Staff failed to confirm the resident's presence after an alarm was triggered, resulting in the resident being found offsite by emergency services and returned to the facility. The facility also failed to properly assess, supervise, and monitor residents during smoking activities. Residents who were identified as dependent smokers, or who had cognitive impairments, were observed smoking unsupervised in facility courtyards. In several cases, residents did not use required safety equipment such as smoking aprons/blankets, and independent smokers were observed assisting dependent smokers in violation of facility policy. Care plans for these residents did not consistently address noncompliance with smoking policies or provide adequate interventions for their supervision needs. Additionally, residents with known wandering behaviors were not effectively monitored or provided with updated care plan interventions following repeated incidents of entering other residents' rooms and engaging in altercations. Despite documented incidents of wandering and aggressive behavior, care plans were not revised to include additional safety measures. Staff interviews confirmed that expectations for monitoring were not consistently met, and multiple incidents occurred where residents with severe cognitive impairment wandered into unsafe situations or other residents' rooms without timely staff intervention.