Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent accidents for three residents, resulting in incidents of elopement, repeated entry into other residents' rooms, and a fall without proper assessment or follow-up. One resident with a history of adjustment disorder, dementia, and severely impaired cognition was identified as an elopement risk and had demonstrated exit-seeking behaviors, including attempting to leave the floor and pushing on doors. Despite this, the only intervention in place prior to the resident's elopement was staff awareness of the wander risk. The resident was able to exit the building, traverse stairwells, and reach the parking lot before being intercepted by staff, indicating a lack of effective supervision and failure to implement additional interventions despite known risks. Another resident with severe cognitive impairment and a history of wandering was observed repeatedly entering other residents' rooms, sometimes attempting to get into their beds. The care plan for this resident included 30-minute checks after wandering incidents, but there was no documentation of these checks or of the resident's behaviors in the clinical record. Staff interviews revealed a lack of awareness and inconsistent documentation regarding the resident's wandering and the required interventions, and the resident experienced multiple falls, including one resulting in a head injury and hospital transfer. A third resident, with intact cognition but significant mobility assistance needs, experienced a fall in their room. The incident was documented as a behavior note rather than a fall, and there was no evidence of a post-incident assessment, incident report, or notification to the resident's physician or legal guardian. The care plan was not updated to reflect the incident, and staff interviews confirmed that the facility's process for fall events was not followed. Facility policies required identification, evaluation, implementation, and monitoring of interventions to reduce accident risks, but these processes were not consistently applied for the residents involved.