Failure to Implement Care Plan Interventions for Supervision, Elopement Risk, and Communication Needs
Penalty
Summary
The facility failed to implement care plan interventions for multiple residents, resulting in significant deficiencies. For several residents identified as being at risk for elopement or exhibiting wandering behaviors, the facility did not consistently follow care plan interventions such as providing adequate supervision, maintaining electronic monitoring devices, or ensuring 1:1 supervision as ordered. In one instance, two residents with severe cognitive impairments and documented elopement risk were able to exit the facility by breaking a window, with one resident later found walking on a highway and the other located at a store. Documentation revealed that staff assigned to 1:1 supervision were not present at critical times, and the facility lacked policies or clear expectations for supervision or 1:1 monitoring prior to these incidents. Another resident with a history of aggressive and impulsive behaviors, as well as a risk for elopement, was not consistently provided with the required 1:1 supervision or engagement in structured activities as outlined in the care plan. Documentation of 1:1 activities was sporadic, and the resident was able to leave the facility, resulting in self-injury and injury to others. Staff reports and progress notes indicated that the resident's behavioral interventions were not reliably implemented, and there were multiple incidents of aggression and attempts to exit the building, some resulting in physical altercations and injuries. Additionally, a resident with communication difficulties and aphasia did not receive the care plan intervention of a communication board, nor was there evidence of referral to speech therapy as required. Despite repeated requests from the resident and his roommate, and documentation in the care plan that a communication board should be provided and evaluated for use, the intervention was not implemented. The care plan also called for a referral to speech therapy, but no such referral or therapy order was found in the resident's records.