Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to ensure that residents remained as free from accidents as possible by not providing adequate supervision and timely, effective interventions for two residents with a history of altercations and falls. One resident, with diagnoses including a history of falls, osteoporosis, and failure to thrive, was independent with ambulation prior to the incident but suffered a fall after being struck multiple times by a roommate's wheelchair. This resulted in significant injuries, including a large hematoma above the left eye and a left hip fracture requiring surgery. The resident expressed ongoing fear for personal safety and reported previous similar incidents involving the same roommate, including a prior fall and injury. The roommate involved in these altercations has a documented history of dementia with agitated and aggressive behaviors, including wandering, physical aggression toward other residents and staff, and refusal of medications. A psychiatric consult recommended 1:1 supervision due to the resident's impulsivity and risk to self and others, but this intervention was not implemented or added to the care plan. There were no documented orders for 1:1 care, and staff interviews confirmed that supervision was inconsistent and not formally assigned. Observations revealed further lapses in supervision and safety, such as the resident being left unsupervised in a wheelchair that did not allow their feet to touch the floor, despite a known history of falls and attempts to stand unassisted. The resident had experienced multiple recent falls, resulting in injuries such as skin tears and blisters. Staff interviews confirmed the resident's restlessness, wandering, and unsafe behaviors, as well as the lack of appropriate supervision and interventions to prevent further accidents.