Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for a resident identified as being at risk for elopement and accidents. During an observation, a resident was found in bed with a breathing treatment in progress and a cup containing six to eight pills at the bedside. The licensed nurse confirmed that she had poured the medications but allowed the resident to delay taking them until after the breathing treatment, despite the resident not being authorized to self-administer medications. This action was not in accordance with the facility's medication administration policy, which requires medications to be administered by licensed staff as ordered and in a manner to prevent contamination or infection. Additionally, the facility's elopement prevention measures were found to be inadequate. The elevator on the second floor required a key for access, but the key was stored in a grievance form box on the wall, visible and accessible to residents and visitors. A staff member acknowledged that the key was not supposed to be stored there but was able to retrieve it easily. Facility leadership confirmed that the key lock was implemented as an additional measure because staff had become desensitized to wander guard alarms. These findings indicate lapses in both medication administration and elopement prevention protocols, as outlined in the facility's own policies.