Failure to Supervise Residents and Secure Smoking Patio Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment and provide adequate supervision to prevent accidents for two residents who were left unsupervised on the smoking patio after the last scheduled smoking time. Both residents had documented needs for supervision while smoking, as indicated by their Smoking Safety Screens and care plans. Despite these requirements, staff did not supervise the residents on the patio at approximately 7:00 p.m., and the door to the smoking patio was not secured after the designated smoking period ended at 6:00 p.m. One resident, who had diagnoses including anxiety disorder, repeated falls, major depressive disorder, and a recent fracture, was assessed as having intact cognition but required substantial assistance with activities of daily living and was only permitted to smoke with supervision and a protective apron. The other resident had severe cognitive impairment and also required supervision while smoking. On the evening in question, the two residents remained on the patio unsupervised, during which time one resident became verbally aggressive and threw a plastic coffee mug at the other, resulting in a bump on the head and escalating pain over the following days. Interviews with staff revealed that CNAs and LVNs were unaware of the residents' whereabouts and did not monitor or redirect them as required. Staff acknowledged that residents sometimes remained on the patio unsupervised after smoking times, and that the patio door was not consistently locked. The facility's policy required supervision and securing of the patio after smoking times, but these procedures were not followed, directly leading to the incident of resident-to-resident aggression and injury.