Failure to Implement Safety Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement required safety interventions for a resident with Alzheimer's disease and other significant medical conditions, who was dependent on staff for activities of daily living and used a wheelchair for mobility. The resident's care plan included interventions such as the use of geri-sleeves for skin protection and a stop sign at the bedroom entry to redirect the resident when unassisted, due to their risk for falls and impaired cognition. Despite these documented interventions, the stop sign was not present in the resident's new room after a room change, and staff did not ensure its implementation. The resident sustained multiple injuries of unknown origin, including a laceration to the nose, nosebleed, hematoma to the forehead, and skin tears, which required hospital evaluation. Following the incident, the only intervention implemented was 15-minute checks for 24 hours, with no additional safety measures put in place. Interviews with the DON confirmed that the stop sign intervention was not in place in the new room and that no further interventions were implemented regarding the resident's safety, despite facility policy requiring modifications to prevent similar incidents.