Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that accident hazards were minimized and adequate supervision was provided to prevent accidents, as evidenced by two separate incidents involving two residents. In the first case, a resident with multiple diagnoses including dementia, congestive heart failure, and impaired decision-making experienced a fall in her room. The fall was discovered by the resident's daughter via electronic monitoring, but there was no documentation of the incident in the medical record, no immediate intervention, and no post-fall assessment or follow-up as required by facility policy. The Director of Nursing confirmed that the nurse on duty did not document the fall, complete an incident report, or implement any new interventions until days later, after being shown the camera footage by the resident's daughter. In the second case, another resident with a history of pulmonary embolism, chronic pain, and no cognitive impairment left the facility in his wheelchair and was found in the middle of a public street. Staff were aware the resident intended to leave to purchase alcohol and attempted to redirect him, but he signed himself out for a leave of absence and remained outside for several hours. Staff did not maintain supervision or check on the resident during this time. The situation escalated to the point where law enforcement and the facility administrator had to intervene to return the resident to the facility. Documentation showed the resident had never previously signed out for a leave of absence, and staff did not contact the physician regarding the resident's request for alcohol. Both incidents demonstrate a lack of adherence to facility policies regarding fall prevention, post-incident assessment, and supervision of residents, particularly those with known risks or behavioral concerns. The facility's failure to document, assess, and intervene appropriately after the fall, as well as the lack of supervision and monitoring of a resident who left the premises, contributed to the deficiencies cited in the report.