Failure to Provide Adequate Supervision and Person-Centered Care Planning for High-Risk Resident
Penalty
Summary
The facility failed to ensure that the care plan accurately reflected the individual care needs of a resident with a history of dementia, high risk for elopement, and high risk for falls. Despite documented assessments indicating the resident's severe cognitive impairment, exit-seeking behavior, and frequent wandering, the care plan did not include timely or adequate interventions to address these risks. The care plan interventions for elopement and falls were only developed after the resident experienced a fall, rather than proactively based on the resident's known behaviors and risks. On the day of the incident, the resident was observed to be unsupervised in the facility's patio, where they sustained a fall resulting in injuries that required transfer to an acute care hospital. Interviews with nursing staff and facility leadership confirmed that the resident's whereabouts were not adequately monitored, and staff were unable to account for the resident's location prior to the fall. The facility's policies required an environment free from accident hazards and person-centered care planning, but these were not followed for this resident, leading to the incident.