Failure to Provide Direct Supervision and Safe Toys for Resident With Mouthing Behavior
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area was free from accident hazards and to provide adequate supervision to prevent an accident for a resident with a known history of mouthing objects. The resident, admitted with a mitochondrial disorder resulting in developmental and intellectual delay and hypotonia, was documented as requiring direct supervision when in a wheelchair. On the day of the incident, the resident was seated in a common/community room in a wheelchair, playing with a battery-powered musical doll. The doll’s rear Velcro pouch was open, the back cap of the battery pack was off, and one of two AA batteries was missing. Staff observed the resident gagging/coughing and appearing as if choking, and an emergent assessment was requested from the NP due to concern for battery ingestion. The facility’s own investigation concluded that the toy was not safe because the screw to the battery compartment was either missing or failed, and that there was documentation supporting the resident’s need for direct supervision in the wheelchair, which did not appear to have been provided at the time of the incident. CNA #1, who was assigned to the resident, reported seeing the resident playing with the musical doll in the community room and leaving the resident there to attend to other assigned residents. CNA #2, who was providing 1:1 supervision to another resident, stated that while he could see this resident, he was not supervising them and that direct supervision could mean either 1:1 or being within arm’s length, indicating inconsistent understanding of supervision requirements. The NP and nursing staff were unable to locate the missing battery on the resident’s person or in the environment, and hospital records later confirmed a battery in the resident’s abdomen, which was removed via endoscopy. Interviews with multiple staff members showed that the resident was well known for frequently putting items and toys in the mouth, and that some of the resident’s battery-operated toys had been sewn shut while others were not. There was no clear process to determine whether facility staff or the resident’s parents/guardians were responsible for ensuring toys were made safe, and the ADON stated that toys brought in by the family were not inspected by nursing staff unless electronic. The ADON and Administrator both acknowledged that the resident had always required direct supervision in the wheelchair and that there was a lapse in the required level of direct staff supervision at the time of the incident. At the time of the survey, the facility did not have a policy defining different levels of staff supervision, and staff expressed uncertainty about whether “direct supervision” meant constant 1:1 observation or proximity-based monitoring.
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