Failure to Provide Adequate Supervision and Accident Hazard Prevention
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with aggressive and wandering behaviors. The resident, who had a history of Alzheimer's disease, dementia, unsteady gait, and recent behavioral changes, was known to wander daily and had exhibited increased agitation, aggression, and confusion in the weeks leading up to the incident. Despite these documented behaviors, the care plan did not reflect all of the resident's aggressive actions, and interventions for supervision and monitoring were inconsistently implemented and documented. On the day of the incident, the resident wandered into another resident's room, despite a prior verbal threat from that resident earlier in the day. The second resident, who also had a history of behavioral symptoms and moderate cognitive impairment, responded by physically assaulting the wandering resident, resulting in a head injury and scalp laceration that required hospital treatment. Staff interviews revealed that there was confusion and lack of clarity regarding who was responsible for monitoring the resident, how monitoring should be documented, and whether there was an official order for 1:1 supervision. Several staff members were not adequately trained or in-serviced on monitoring procedures or documentation requirements for the resident in question. The facility's own policy required identification, evaluation, and intervention for hazards and risks, as well as monitoring for effectiveness and modification of interventions as necessary. However, the report documents that the resident's care plan was not updated to include all aggressive behaviors, and staff were not consistently informed or trained on the monitoring expectations. This lack of comprehensive and coordinated supervision and documentation directly contributed to the incident in which the resident was injured after wandering into another resident's room and being assaulted.