Failure to Prevent Accidents, Elopement, and Falls Due to Inadequate Supervision and Care Plan Implementation
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in multiple incidents of harm. One resident with severe cognitive impairment and a history of wandering was able to elope from the facility without staff knowledge. The front desk staff observed the resident leaving but did not intervene or follow elopement protocols, and there was a delay in calling 911 due to confusion about staff responsibilities. The resident was later found by a member of the public after experiencing a fall. Another resident at risk for elopement did not consistently have a Wander Guard device in place, as required, with documentation showing multiple missed opportunities to ensure the device was present and functioning. The facility also failed to provide the required level of assistance during care, resulting in avoidable injuries. One resident, who was totally dependent on staff for repositioning and required two staff members for bed mobility, was assisted by only one staff member, leading to a fall and a laceration near the eye that required hospital treatment. Despite care plan requirements, staff continued to provide care with only one person. Another resident with recent hip surgery and specific hip precautions experienced a dislocation and severe pain during a transfer when staff failed to follow the required precautions. The care plan and provider orders for hip precautions were not properly implemented or communicated. Additionally, the facility did not consistently assess the effectiveness of interventions or revise care plans in a timely manner following falls. One resident experienced three falls within a short period, resulting in injuries including a head laceration and hematoma, but the care plan was not updated with new interventions after the first two falls. Another resident, at high risk for falls and with a history of impulsivity, was left unattended after expressing intent to get out of bed, leading to a fall. In several cases, required safety equipment such as reacher tools and call lights were not kept within reach, and staff did not remain with residents at risk until help arrived.