Failure to Provide Adequate Supervision and Prevent Accident Hazards
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision for a resident with dementia, anxiety, a history of falls, and impulsive behavior. Despite being identified as high risk for falls and self-harm, the resident experienced eight unwitnessed falls over a period of several months. The care plans for the resident included specific interventions such as being checked and changed every two hours, frequent visual monitoring, and later, checks every 30 minutes. However, there was no documented evidence that these interventions were consistently implemented or monitored by staff. On multiple occasions, the resident was found on the floor or under her roommate's bed, sometimes with visible injuries such as hematomas, skin tears, and severe bruising to the face and hands. Staff interviews revealed that CNAs were aware of the resident's behaviors and risks, but failed to consistently report significant findings, such as swollen eyes, to the nursing staff in a timely manner. Additionally, CNAs reported that their concerns about the resident's safety and the need for increased supervision, such as a one-on-one sitter, were communicated to nursing leadership but not acted upon. Record reviews confirmed the lack of documentation for required monitoring and supervision as outlined in the resident's care plans. The DON acknowledged that the facility did not follow its own policies and procedures for ensuring resident safety and that the falls could have been avoided with proper monitoring. The facility's policy required targeted interventions and adequate supervision to reduce accident risks, but these were not effectively implemented for this resident.