Failure to Supervise Cognitively Impaired Wheelchair User in Parking Lot
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention measures for a cognitively impaired, wheelchair-bound resident who was allowed to be outside unsupervised. Surveyors observed that the facility had a large parking lot directly connected to a u‑shaped driveway and the main entrance, with no caution signage, patio seating, or safety barriers for pedestrians despite expected vehicle traffic. The entrance doors were automatic sliding doors that opened by motion sensor, and the receptionist’s view of the entrance was obstructed by a tall countertop with items on it. The facility did not have staff assigned to monitor exits or the parking lot, and exit doors were unlocked and lacked alarms. The resident involved had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side and used a wheelchair. The resident’s MDS showed a BIMS score of 9, indicating moderate cognitive impairment. Despite this, the resident’s care plan did not include interventions addressing the risk for injury related to impaired cognition. Staff interviews, including with the DON, LVN, CNA, and COTA, confirmed that the resident had impaired judgment, was oriented only to self and place, and required increased supervision, particularly when outside. Staff also stated that residents with cognitive impairment should not be on the front patio or in the parking lot without supervision. On the day of the incident, the resident requested candy from the receptionist and then exited to the front patio unsupervised through the automatic doors. While the resident was propelling the wheelchair in the left side parking lot, a small white SUV was backing out of a parking space. The resident was behind the vehicle, and the driver did not see the resident, striking the left side of the wheelchair. Witnesses honked and alerted the driver while the resident yelled for the car to stop. The resident subsequently reported left elbow discomfort, and hospital documentation recorded a diagnosis of pain in the left elbow. The COTA stated that a resident with cognitive impairment should not be outside without supervision and that the incident could have been prevented by the facility.
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