Failure to Provide Adequate Supervision During Outdoor Activities
Penalty
Summary
The facility failed to provide adequate supervision for a resident with multiple diagnoses, including unspecified dementia, psychotic disturbance, mood disturbance, anxiety, sensorineural hearing loss, and major depressive disorder, during outdoor relaxation time. Facility policy allowed residents not at risk for elopement or wandering to use outdoor areas within designated boundaries during daylight hours. However, observations on two separate days showed that three to four residents were outside without staff supervision. Specifically, one resident was seen propelling himself in a wheelchair beyond the designated safe zone, around an oval road where vehicles were present, without staff oversight. During one observation, the resident, who was not wearing his hearing aids, was seen moving toward the curb and into areas with oncoming traffic. The resident reported that he regularly completed multiple laps around the oval road daily and suggested that increased visibility, such as a flag or safety vest, would improve his safety. Staff interviews confirmed that it was unsafe for the resident to be unsupervised in these circumstances, especially given his medical conditions and the presence of vehicular traffic.