Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement effective fall interventions for a resident with a history of repeated falls and cognitive impairment. One resident, who had diagnoses including hemiplegia, hemiparesis, muscle weakness, and a history of stroke, experienced 12 falls over a six-month period. On one occasion, the resident was left unsupervised in the bathroom after being assisted onto the toilet by an occupational therapy assistant (OTA). The OTA placed the call light in the resident's hand and verbally instructed her to call for assistance when ready, then notified a nursing assistant (NA) outside the room. However, the assigned NA was not aware the resident was in the bathroom, and the resident attempted to transfer herself, resulting in a fall and a left ankle fracture. Staff interviews revealed inconsistent understanding of the resident's supervision needs, and documentation did not reflect the resident's fall risk accurately on the MDS assessment. Additionally, the facility failed to provide adequate supervision for a cognitively impaired resident with Alzheimer's dementia who was at risk for elopement. This resident exited the facility unsupervised on two separate occasions. In the first incident, the resident was able to leave the building when a receptionist opened the door for visitors, and staff were unaware of her absence until she was observed outside. There was no clear system in place to identify elopement risk residents to all staff, and the incident was not documented in the facility's incident log. In the second incident, the resident was again found outside the building by a receptionist, and staff were unable to state when the resident was last observed on the unit. The care plan for this resident included frequent checks and ensuring hallway doors were alarmed, but these interventions were not effectively implemented. Interviews with staff, including nurses, nursing assistants, and administrative personnel, revealed gaps in communication and supervision practices. There was a lack of clear documentation and investigation of the incidents, and staff were often unaware of the residents' whereabouts or supervision needs at the time of the events. The facility's failure to maintain a safe environment and provide adequate supervision resulted in preventable accidents, including a fall with injury and two elopement incidents involving residents with known risks.