Failure to Prevent Resident Self-Harm and Elopement Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, with a history of depression, anxiety, and a prior hospitalization for suicidal ideation, was able to access a shaving razor and attempted to injure herself by cutting her wrist. Despite her previous hospitalization for suicidal ideation and recommendations from a hospital psychiatrist for closer observation or placement in a secure unit, the resident was returned to the general population without enhanced supervision or environmental controls to prevent self-harm. The care plan did not reflect her history of suicidal ideation or the need for increased supervision, and there was no documentation of interventions specifically addressing her risk for self-injury after her return from the hospital. Staff interviews revealed that the resident's mood and behavior changes were known, and some staff expressed concerns about her safety and the appropriateness of her placement outside of a secure unit. The resident was able to obtain a razor, possibly from personal items brought in by family or from an unlocked utility room containing razors and other potentially hazardous items. The facility's policies required incident reporting for self-inflicted injuries and suicide attempts, but the administrator initially did not believe the incident required reporting. The environment was not adequately controlled to prevent access to dangerous items, and staff supervision and monitoring were insufficient to prevent the resident's self-injury. In a separate incident, another resident with severe cognitive decline and a history of wandering and exit-seeking behavior eloped from the memory care unit. The baseline care plan documented the resident's risk for elopement, but effective measures were not implemented to prevent the resident from leaving the secure area. These failures in supervision and environmental safety placed residents at risk for harm and resulted in the identification of Immediate Jeopardy by surveyors.