Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision for three residents. One resident with dementia and a history of wandering and exit-seeking behaviors eloped from the facility after a malfunctioning door was not properly addressed. Despite repeated maintenance work orders indicating the door was not latching properly, there was no documentation of effective interventions to ensure the resident's safety. Staff interviews revealed a lack of awareness about which residents were at risk for elopement, and the concierge allowed the resident to exit, mistaking them for a visitor. The resident was later returned by police. Another resident with mild cognitive impairment and a history of subdural hemorrhage was observed to have unopened wine bottles unsecured at their bedside over several days. The resident's care plan and medical orders did not address personal alcohol possession or consumption, and staff interviews revealed inconsistent knowledge and practices regarding residents keeping alcohol in their rooms. There were also other residents with wandering tendencies on the same unit, increasing the risk of unauthorized access to the alcohol. A third resident, who had muscle weakness and a thoracic wedge compression fracture, used a right-sided transfer bar for bed mobility. Observations revealed a gap of approximately four inches between the transfer bar and mattress, creating a potential entrapment hazard. The facility could not provide documentation that transfer bar and bed safety checks were performed every shift as required. Interviews indicated that the resident was not included on the list for quarterly transfer bar assessments, and the required safety checks were not documented until after the deficiency was identified.