Failure to Prevent Accidents and Implement Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. One resident with a history of dementia, stroke, and wandering behaviors experienced an elopement event, leaving the facility unsupervised and traveling several blocks to a representative's workplace. Despite this incident and a subsequent assessment identifying the resident as high risk for elopement, the care plan was not updated to include interventions to prevent recurrence, and the resident's wanderguard was discontinued based on a verbal agreement rather than documented risk mitigation. Staff interviews revealed inconsistent awareness and implementation of elopement precautions, and the resident was observed without a wanderguard or clear supervision protocols in place. Another resident, admitted with end-stage heart failure, schizophrenia, and a history of falls, was identified as a high fall risk but did not receive consistent fall prevention interventions. The resident experienced multiple falls during their stay, including one incident where they pulled out a Foley catheter and slipped in urine, and another unwitnessed fall found by a representative. Documentation failed to consistently record whether the resident was using supplemental oxygen at the time of falls, and vital signs, including oxygen saturation, were not always documented after incidents. The care plan included general fall prevention strategies but lacked specific interventions tailored to the resident's needs and did not reflect the use of supplemental oxygen, despite its clinical relevance. A third resident with Huntington's disease and a history of falls was not consistently provided with care plan interventions such as staff escort to and from meals and visual reminders to call for assistance before transferring. Observations showed the resident self-transferring without staff assistance or using the call light, and the required reminder sign was missing from the room after a recent move. There was no evidence that the care plan was reviewed or updated following a recent fall, and staff interviews confirmed lapses in implementing and maintaining fall prevention measures.