Failure to Implement Care Plan Interventions for Resident Safety and Supervision
Penalty
Summary
Staff failed to implement care plan interventions for three residents, resulting in deficiencies related to resident safety and supervision. For two residents, after an alleged incident of sexual abuse where one resident touched another's legs, care plans were updated to require separation and increased supervision. However, observations showed that these two residents continued to sit together and interact in the lobby, with one resident placing a pillow under the other's legs. Interviews with staff revealed a lack of awareness and enforcement of the separation intervention, and the residents themselves were not informed that they should not be together. The Director of Nursing confirmed that staff did not follow the care plan interventions to keep the residents separated after the abuse allegation. Another resident, identified as an elopement risk due to a history of leaving the facility without authorization, had a care plan requiring monitoring of her location and documentation of wandering behavior. Despite this, the resident left the facility without notifying staff or signing out, and her absence was not noticed until several hours later. Staff interviews indicated that monitoring was not performed as required by the care plan, and the Director of Nursing acknowledged that the failure to monitor allowed the resident to leave unsupervised. Record reviews and staff interviews confirmed that the facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables to be developed and implemented for each resident. In these cases, the interventions specified in the care plans were not carried out, resulting in lapses in resident safety and supervision. The deficiencies were directly related to staff not being aware of, or not following, the care plan interventions for separation after an abuse allegation and for monitoring a resident at risk for elopement.