Failure to Prevent Resident Accident Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, schizophrenia, falls, and wandering was not adequately supervised, resulting in the resident accessing an alarmed stairwell door and falling down the stairs in their wheelchair. The resident sustained two fractured vertebrae and a scalp hematoma. The resident's care plan documented wandering and elopement risk, and interventions included monitoring while in a wheelchair. However, after a prior incident involving resident-to-resident aggression and documented wandering, there was no evidence that increased supervision or additional interventions were implemented to address the resident's ongoing wandering behavior. On the day of the incident, the resident was placed in the Day Room by staff to be monitored but was observed multiple times moving independently in the hallway. Despite being redirected once, the resident was able to access the stairwell door, which was alarmed but could be opened after a period of continuous pressure. Staff were providing care in another room when the alarm sounded, and there was a delay in responding to the alarm. Video surveillance confirmed that the resident was able to open the stairwell door and enter the stairwell unaccompanied, leading to the fall. Interviews with staff revealed that they were aware the resident had a tendency to wander and approach doors, requiring redirection. The alarm system on the stairwell door was known to allow the door to open after a certain period, even while sounding. There was no evidence of additional visual cues or barriers, such as stop signs, on the stairwell doors as planned. The lack of timely supervision and effective interventions to prevent the resident from accessing the stairwell resulted in the resident's fall and injuries.