Failure to Prevent Accident Hazards and Provide Supervision for High-Risk Resident
Penalty
Summary
Facility staff failed to ensure an environment free from accident hazards and did not provide adequate supervision for a resident with a history of suicidal ideations, major depressive disorder, and bipolar disorder with psychotic features. The resident was assessed as cognitively intact, at high risk for falls, and at risk for wandering. Despite these risks, the resident was repeatedly found outside the facility unsupervised, smoking cigarettes obtained from the ground, and attempting to leave the premises. The resident's care plan included interventions for self-care deficits, fall risk, and behavioral issues, but these were not effectively implemented to prevent the resident from accessing hazardous areas or engaging in unsafe behaviors. Multiple nursing notes documented incidents where the resident was found outside, sometimes in the driveway or attempting to leave, and on one occasion, the resident fell while outside, hitting his head and abdomen. Staff were aware of the resident's revoked smoking privileges due to policy violations, yet the resident continued to access cigarettes and lighters. Observations by the surveyor confirmed the resident was outside unsupervised, and staff acknowledged this was a recurring issue. Facility policy required supervision and secure storage of smoking materials, but these measures were not consistently enforced for this resident.