Failure to Supervise and Implement Safety Measures for Residents at Risk
Penalty
Summary
The facility failed to provide adequate supervision and implement safety measures for multiple residents, resulting in deficiencies related to accident hazards and prevention. One resident with severe cognitive impairment, metabolic encephalopathy, and dysphagia was observed eating a pureed diet alone in his room without staff supervision, despite orders and speech therapy recommendations for 1:1 supervision at all meals due to swallowing difficulties. Staff interviews confirmed that this resident should not have been left unsupervised while eating, as he required constant reminders and cueing to ensure safe swallowing practices. Another resident with a history of unsteadiness, falls, and maximum assist needs for transfers was transferred from bed to wheelchair by a CNA without the use of a gait belt, contrary to facility policy and care plan instructions. The CNA held the resident under the arms instead, and the resident reported that gait belts were only used during therapy sessions, not in her room. The Director of Rehab confirmed that a gait belt should be used at all times for this resident due to her high fall risk and potential for sudden weakness during transfers. Additionally, a resident with dementia, hemiplegia, and dysphagia was repeatedly observed eating pureed meals alone in her room with the privacy curtain drawn, making her invisible from the hallway. Both the facility dietician and DON stated that this resident required supervision at all meals due to her high risk of choking and aspiration. Another resident with a traumatic brain injury and high fall risk was found alone in her room with the door and blinds closed, contrary to posted safety instructions and care plan interventions. The care plan had not been updated to reflect a recent fall with injury, and required fall precautions were not consistently maintained.