Failure to Implement Care-Planned Safety and Privacy Intervention After Resident-to-Resident Incident
Penalty
Summary
Surveyors found that the facility failed to implement a care-planned intervention for a resident who had requested enhanced safety and privacy measures after a resident-to-resident incident. A complaint reported to the State Agency documented that one resident entered another resident's room wearing only a brief and frightened the resident. The affected resident had diagnoses including generalized anxiety disorder, recurrent moderate major depressive disorder, adjustment disorder, osteochondrodysplasia with defects of growth of tubular bones and spine, short stature due to an unspecified endocrine disorder, and neuralgia and neuritis, and was assessed as having intact cognition. In response to the resident’s expressed desire for enhanced safety and privacy, the care plan initiated by a former MDS coordinator included placing a red stop sign on the resident’s door as a visual cue to discourage uninvited entry and reinforcing the resident’s rights to privacy and safety. During multiple observations on different days, surveyors noted that there was no Velcro stop sign placed within the resident’s doorway, despite the care plan intervention remaining active and not discontinued. Another resident involved in the prior incident was observed lying in bed in a room located directly across from the affected resident’s room. In an interview, the CNA assigned to the resident stated they had worked at the facility for a year and had never seen a Velcro stop sign for that resident. The DON, who began employment after the incident and after the care plan was initiated, confirmed that if the intervention was in the care plan it should have been in place, and acknowledged that Velcro stop signs were available in the facility. The facility’s policy on comprehensive care plans stated that each resident has the right to receive the services and items included in their plan of care.
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