Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
Surveyors identified deficiencies in the facility's ability to maintain a safe environment free from accident hazards and to provide adequate supervision to prevent accidents for three residents. For one resident with peripheral vascular disease, hypertension, and glaucoma, the corridor door to their room was repeatedly observed to be stuck or unable to be freely opened or closed while the resident was present in the room. Multiple staff interviews confirmed the issue was not previously noticed, but the door was later found to be functioning properly after the observations. Another resident with schizophrenia, traumatic brain injury, and epilepsy, who was identified as an elopement risk, experienced two separate elopement incidents. The resident was not wearing a wander guard and was able to leave the facility on both occasions. Staff failed to update the care plan or document interventions after these incidents, and interviews revealed that the resident would not keep a wander guard on and required close monitoring, which was not consistently provided due to staffing challenges. The facility's own policies for elopement were not followed, and the incidents were not properly investigated or documented at the time. A third resident with hemiplegia, major depressive disorder, and severe cognitive impairment eloped from the facility while on 30-minute safety checks. The resident exited through a side door by holding the release for fifteen seconds, triggering an alarm that was not responded to by unit staff. The resident was found outside by staff, sustained a laceration after a fall, and was sent to the hospital. There was no documented investigation into how the resident was able to exit unnoticed, and staff interviews indicated a lack of awareness and follow-up regarding the alarm and the resident's absence.