Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to prevent accidents and provide adequate supervision for three residents, resulting in significant safety incidents. One resident with severe cognitive impairment and a documented history of elopement, including previous attempts to exit through windows, was not adequately supervised or protected. Despite multiple documented incidents of window exit-seeking and staff awareness of these behaviors, the resident was able to open a second-floor window and fall, resulting in multiple fractures and hospitalization. The care plan did not include individualized interventions for window elopement, and staff failed to notify management, the physician, or the resident's guardian of escalating behaviors and repeated elopement attempts. Additionally, the facility did not ensure that windows were properly secured, despite prior knowledge of the risk and an incomplete window audit. Another resident with dysphagia and a history of choking was trialed on an upgraded diet texture without a physician's order and without the speech therapist remaining present for supervision. The resident choked on a chicken sandwich and required the Heimlich maneuver to clear the airway. The resident's care plan and diet orders were not clear or properly followed, and staff interviews confirmed that the process for trialing new food textures was not adhered to, placing the resident at risk. A third resident, assessed as requiring supervision for smoking, was found with unsupervised smoking materials in their room and was observed attempting to leave the building with a cigarette. The facility's policy required that supervised smokers not have access to smoking paraphernalia in their rooms, and that all such materials be stored securely. However, the resident's care plan did not include individualized interventions for smoking, and staff acknowledged that the policy was not being followed, with residents able to access and use smoking materials without proper supervision.