Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards for two residents with cognitive impairments and special dietary needs. One resident with Alzheimer's disease and a mechanical soft diet was observed repeatedly accessing and consuming discarded food from an unattended meal cart in the dining room without staff intervention. The resident was also given a sandwich that did not meet her dietary restrictions, resulting in her struggling to eat and dropping food on the floor. Multiple staff interviews confirmed that there were not enough staff present to monitor residents adequately, and that dietary orders were not consistently followed, increasing the risk of choking for the resident. Another resident with dementia and severe cognitive impairment, who required substantial assistance with eating, was left unsupervised in the dining room. This resident sustained second- to third-degree burns after spilling hot coffee on herself. The coffee was provided without a lid, despite care plan instructions, and staff acknowledged that the coffee was too hot and that a lid was needed. The staff member responsible was distracted due to short staffing and did not return with the lid before the resident was given the coffee. The burn resulted in significant injury, including blistering and pain, as documented in the resident's medical record and skin evaluation photos. Staff interviews consistently reported ongoing staffing shortages, which contributed to lapses in supervision, failure to follow dietary orders, and inability to provide adequate care. Staff expressed concerns about being unable to monitor all residents, leading to missed care and increased risk of harm. Grievance forms and care plan reviews further documented these deficiencies, with staff acknowledging that the current staffing levels made it difficult to ensure resident safety and compliance with care requirements.