Failure to Prevent Accident Hazards and Ensure Resident Supervision
Penalty
Summary
A resident with dementia and severely impaired cognition, who was at risk for wandering and elopement, was required to wear a Wander Guard device on both her wrist and wheelchair to prevent unauthorized exit from the facility. On one occasion, a staff member opened the entrance door for a visitor, and the resident was able to exit the facility undetected. The root cause was that an overnight shift nurse had removed the resident's Wander Guard prior to a medical appointment and failed to document its removal or communicate this to the day shift nurse. Upon the resident's return, the Wander Guard was not replaced, yet nursing staff continued to document that the device was present and functioning, despite it not being worn. In a separate incident, another resident was being transported by a facility-operated bus when the transport driver failed to secure the resident's wheelchair with the required floor straps. During the trip, the wheelchair tipped, causing the resident to hit her arm and sustain a scrape. The transport driver acknowledged not securing the wheelchair and only did so after the incident occurred. The driver had previously completed competency training for loading wheelchair passengers. Both incidents involved failures by staff to follow established safety protocols, including proper use and documentation of safety devices and adherence to transport safety procedures. These lapses resulted in residents being placed at risk for harm or injury due to inadequate supervision and failure to eliminate accident hazards.