Failure to Provide Required Supervision and Follow Safety Care Plan
Penalty
Summary
The facility failed to provide necessary supervision and follow the safety care plan for a resident with severe cognitive impairment and agitation. The resident's care plan required that staff accompany them when leaving the unit or, if staff were unavailable, that security be notified. Despite these requirements, the resident was allowed access to the elevator and went to the first-floor lobby unaccompanied and without security being informed. During this time, the resident was involved in a verbal exchange and was struck in the face by another individual. Interviews with facility staff, including the Infection Preventionist/Charge Nurse, Assistant Director of Nursing, and Director of Nursing, confirmed that the resident was not accompanied as required and that the care plan was not followed. Documentation and investigation reports also indicated that staff did not provide the necessary supervision or notify security, as outlined in the resident's care plan. This lapse in supervision and failure to adhere to the care plan placed the resident at risk for injury.