Failure to Provide Supervision and Assistance with Toileting and Ambulation
Penalty
Summary
The facility failed to follow care-planned interventions and provide adequate supervision and assistance with toileting for a resident with severe cognitive impairment, a history of falls, and multiple comorbidities including dementia, visual loss, and chronic kidney disease. Observations revealed that the resident was left unsupervised in their room, stood up from their wheelchair without locking the brakes, and ambulated independently to their closet and bathroom on multiple occasions. The resident was also observed to change their socks and slippers and propel themselves in the wheelchair without staff assistance. During one incident, the resident exposed themselves to the hallway while attempting to use the bathroom unassisted, and the wheelchair rolled and struck the bathroom door, creating a potential hazard. Record review indicated that the resident had several unwitnessed falls in recent months and required staff assistance for activities of daily living, including ambulation, transfers, and toileting, as documented in their care plan. Despite these interventions being in place, staff did not consistently provide the required supervision or assistance, resulting in the resident performing activities independently that should have been assisted. Interviews with staff confirmed the resident's poor safety awareness and cognitive impairment, further emphasizing the need for adherence to care-planned interventions.