Failure to Document and Implement Required Safety Checks for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that adequate supervision and safety monitoring interventions were consistently implemented and documented for a resident with severe cognitive impairment and a history of self-injurious behavior. The resident, diagnosed with Alzheimer's Disease and other conditions, had a care plan addressing behaviors such as chewing on nonfood items and placing fingers in their mouth. Despite these known risks, the resident was observed biting their left middle finger, resulting in traumatic amputation and subsequent hospitalization. Upon return from the hospital, physician orders were issued for hourly safety checks, later changed to 15-minute safety checks. However, there was no documented evidence that these safety checks were completed as ordered. Multiple interviews with staff, including LPNs, CNAs, and the DON, confirmed that while procedures for documenting safety checks existed—primarily using paper forms—no records could be produced to show that the required monitoring was performed for this resident during the relevant period. The facility's own policy required prompt, accurate, and legible documentation of 15-minute safety checks for residents at risk, yet review of accountability forms and care guides revealed no such documentation. The absence of these records indicated that the facility did not follow its own protocols or physician orders for monitoring, resulting in a lack of evidence that adequate supervision was provided to prevent further self-injurious behavior.