Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions for multiple residents, resulting in deficiencies related to accident hazards and resident safety. One resident, who was identified as an elopement risk upon admission and had a history of wandering, was not provided with necessary interventions such as a Wanderguard or increased supervision. This resident was able to leave the facility unnoticed and was found walking down a busy street by a staff member on break. There was no documentation of a full assessment, vital signs, or follow-up monitoring after the resident was returned to the facility. Two residents who were identified as smokers did not have smoking assessments or care plans in place, despite facility policy requiring such evaluations upon admission. Staff interviews confirmed that smoking assessments and care plans were expected but not completed. Both residents were observed smoking on multiple occasions, and staff described informal processes for supervising smoking, but there was no formal documentation or individualized planning to address their safety needs related to smoking. Another resident who voiced suicidal ideations did not have a trauma assessment or care plan for suicidal ideations, and there was no documentation of notification to the DON, provider, or family. Staff interviews revealed inconsistent understanding of the required procedures following suicidal statements, and the resident was placed on 1:1 supervision without clear documentation or follow-up. Additionally, a resident at risk for falls did not have fall interventions in place, and fall interventions were not present on CNA care cards or the resident's Kardex, despite being listed in the care plan. Staff were unclear about the current fall interventions, and there was a lack of consistent documentation and implementation of fall prevention measures.