Failure to Supervise Cognitively Impaired Resident and Control Access to Medication in Lobby Area
Penalty
Summary
The deficiency involves the facility’s failure to provide effective supervision and maintain an environment free from accident hazards for a cognitively impaired resident with known wandering and rummaging behaviors. The resident had Lewy body dementia and other significant medical diagnoses, including atrial fibrillation, hypertension, diabetes, COPD, heart failure, thyroid disease, and kidney disease. The resident’s care plan identified risk for cognitive decline related to delirium history and neurocognitive disorder with Lewy body dementia, with an intervention to monitor, document, and report changes in cognitive function. The quarterly MDS documented moderate cognitive impairment and wheelchair use, and staff interviews described a pattern of wandering throughout the facility, entering other residents’ rooms and common areas, and rummaging through belongings, with staff reporting difficulty redirecting the resident. On the day of the incident, the resident was in the lobby area, which is an open common area with television and seating where residents can freely sit and propel their wheelchairs. The receptionist’s desk is located in this lobby area near the facility entrance. The Unit Coordinator reported that the receptionist left her desk unattended, with an unlocked desk drawer containing a loose over-the-counter cold and flu gel capsule. As the receptionist returned to the desk, she observed from across the room that the resident had opened the unlocked drawer, found the loose gel capsule, and ingested it before staff could intervene. The Unit Coordinator stated that residents were frequently in the front common area and that most residents did not wander or go into things, but there was no system in place to ensure continuous monitoring of residents in that area. Following ingestion of the cold and flu gel capsule containing acetaminophen, dextromethorphan, and phenylephrine, the resident initially appeared to be okay but then became drowsy and lethargic, according to the Unit Coordinator and Weekend Supervisor. A nursing note documented that the resident went through the unattended receptionist’s desk, found the capsule, and ingested its contents. Another nursing note later documented that the resident was lethargic and not responding after ingesting the medication and was sent to the emergency department for evaluation of altered mental status. The emergency department record indicated the resident arrived with stable vital signs and a history that her altered mental status began after ingesting the over-the-counter cold and flu medication taken from the receptionist’s desk drawer. The DON and Administrator both acknowledged that the resident should have been supervised and kept free from hazards, and that prior to this incident the facility had not considered unlocked drawers in the lobby area as a potential hazard for cognitively impaired residents, and there was no system to ensure continuous monitoring of residents in common areas, including the lobby.
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