Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to ensure safe transportation of a resident in a wheelchair and did not provide adequate monitoring to prevent a resident from exiting the facility without a responsible party. One resident, who had diagnoses including heart failure, peripheral vascular disease, diabetes, muscle weakness, anxiety disorder, and major depressive disorder, was dependent on staff for wheelchair transport. In September, a CNA accidentally hit the resident's right foot against a wall while turning into the resident's room, resulting in pain and swelling. Although an x-ray showed no fracture at that time, the resident later returned from the hospital with a fractured right toe. The CNA and the Director of Nursing Services (DNS) confirmed the incident, but no safety training or interventions were implemented to prevent recurrence. Additionally, the facility lacked a policy on transporting residents in wheelchairs. Another resident, with diagnoses including schizoaffective disorder, bipolar type, post-traumatic stress disorder, and anxiety, left the facility alone and went to a nearby gas station for snacks. The resident was cognitively intact according to the most recent assessment, but his physician's orders specified that he should only leave with a responsible party. Staff found the resident between the facility's front doors upon his return and assessed him for injuries, finding none. The resident's care plan was updated after the incident, and a wanderguard was applied for safety. The physician noted that the resident had a history of impulsive behavior and poor decision-making, and did not recommend independent leave of absence due to the risk of injury. Interviews with facility leadership revealed that there was no accident policy in place and no specific policy for transporting residents in wheelchairs. The facility's leave of absence policy required a physician's order and specified that residents should only leave with a responsible party unless an independent leave of absence was ordered. The lack of adequate supervision and absence of clear policies contributed to the deficiencies identified for both residents.