Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision and assistance to prevent accidents for three residents. In one incident, a male resident with severe cognitive impairment and a history of wandering and behavioral issues entered another resident's room in the memory care unit while unsupervised. He assaulted a female resident, causing multiple bruises to her face and forearm, and also struck a nurse with a plunger and a stethoscope. The incident occurred after a CNA left the unit to seek additional staff assistance, leaving the area unsupervised. The assaulted resident was found crying and distressed, with visible injuries, and required transport to the emergency room for evaluation. Documentation and interviews confirmed that the aggressive resident had not previously exhibited such behavior, but the lack of supervision allowed the incident to occur. In a separate event, another male resident with moderate cognitive impairment and a high risk for falls was left unsupervised for several hours during the night. The resident fell at midnight while attempting to walk unassisted and remained on the floor until nearly 5:00 AM before being discovered by staff. Video evidence showed that no staff checked on him during this period, despite care plans indicating he required assistance with mobility and regular checks. The resident sustained bruising and an abrasion as a result of the fall. Staff interviews revealed that the assigned CNA became overwhelmed with other resident care tasks and failed to check on the resident, while the nurse on duty did not verify the resident's status during the night. Both incidents demonstrate a failure to provide adequate supervision and assistance as required by the residents' care plans and assessments. The lack of timely staff intervention and monitoring directly resulted in resident injuries and distress. The facility's inaction in maintaining appropriate supervision and assistance for residents with known risks contributed to these deficiencies.