Failure to Prevent Resident Access to Hazardous Items Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to a resident with Alzheimer's disease, dementia, and altered mental status, resulting in repeated incidents where the resident consumed or attempted to consume hazardous non-food items. The resident's care plan and medical records documented ongoing behaviors such as wandering, entering other residents' rooms, and ingesting substances like shampoo, lotion, liquid soap, potting soil, and body wash. Despite these documented risks and the resident's cognitive impairment and poor decision-making skills, the facility did not implement sufficient supervision or environmental controls to prevent access to these hazards. Multiple progress notes and staff interviews confirmed that the resident was frequently found with inappropriate items in her mouth, including potting soil, coffee from other residents' mugs, and used cigarette butts. Staff consistently reported that the resident would grab random objects, food, and drinks belonging to others, and had a history of eating non-food items from various locations within the facility, such as the dining room, hallways, and smoking patio. Observations during the survey also showed the resident attempting to take items from used lunch tray carts and holding coffee mugs that did not belong to her. Interviews with CNAs, LPNs, and the DON revealed that the staff were aware of the resident's behaviors and the need for close supervision, with some staff indicating that one-on-one supervision was sometimes necessary but not provided. The DON acknowledged that the resident should not have been able to access other residents' rooms or their personal items, and the administrator recognized the ongoing safety issues related to the resident's behaviors. The facility's failure to provide adequate supervision and prevent access to hazardous items resulted in repeated incidents that placed the resident at risk.