Failure to Supervise Residents and Secure Courtyard Exit
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for residents with unrestricted access to the outdoor courtyard area. During an observation with the DON, the Garden exit door was found propped open, despite signage instructing that the door should remain closed and indicating it was not an exit. This door, located out of view of the nursing units, was not connected to the wander guard or alarm system. During the observation, a resident was seen unattended in the courtyard, another resident was attempting to exit to the courtyard, and visitors were also observed using the door. The DON confirmed that the door should not have been propped open at that time. Interviews with the NHA, DON, and ADON confirmed that the courtyard had recently become the designated smoking area and that the unsecured door allowed any mobile resident to exit the building when propped open, as it only locks when properly closed. The facility leadership acknowledged that this situation resulted in a failure to provide adequate supervision and maintain a safe environment for mobile residents, as required by facility policy and state regulations.