Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for multiple residents, resulting in both resident-to-resident altercations and unwitnessed falls. On two separate occasions, one resident physically pushed another, resulting in scratches and a fall, with both incidents occurring without staff witnessing the events. The care plan for the resident exhibiting physical behaviors did not address these behaviors, and the secured unit was inadequately supervised, as only one staff member was often present to oversee all residents. Staff interviews confirmed that the staffing was insufficient to provide proper supervision, with staff unable to monitor all residents while performing other care duties. Several residents experienced unwitnessed falls, some resulting in significant injuries such as fractures, lacerations, and emergency room visits. These incidents occurred in various locations, including hallways, dining rooms, and other residents' rooms, and were not observed by staff at the time. Care plans for some residents did not address fall risks, and interventions such as fall mats and supervision were inconsistently implemented or not effective due to lack of staff presence. Staff reported being overwhelmed and unable to complete all assigned tasks, including supervision and documentation, due to being the only staff member on the secured unit. Observations and interviews revealed that residents were frequently left unsupervised in common areas, including the dining room and hallways, sometimes for extended periods. Staff, including nurses and CNAs, reported that the nurse assigned to the secured unit often had to cover other areas, leaving only one person to supervise multiple residents with high care needs. The Director of Nursing and other staff acknowledged ongoing staffing shortages and the inability to provide adequate supervision, which contributed to the pattern of unwitnessed incidents and altercations among residents.