Failure to Supervise High-Risk Wandering Resident in Patio Area
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment for a resident with severe cognitive impairment and a known history of wandering and high fall risk. The resident had Alzheimer’s disease, a BIMS score of 0/15 indicating severe cognitive impairment, and was assessed as high risk for falls and injury due to unsteady gait with a front‑wheel walker, incontinence, confusion, wandering, and behavioral issues. A separate elopement and wandering risk assessment scored the resident at 18, above the threshold indicating risk for wandering or elopement. The resident’s fall care plan, reviewed on 2/7/25, specifically included an intervention that staff would monitor and assist the resident while ambulating in the patio. On the day of the incident, the resident was last seen by the assigned CNA around 6:25 p.m. when incontinent care was provided in the resident’s room; the CNA did not see the resident again until learning of the fall around 7:00 p.m. A hallway monitor CNA observed the resident walking toward another station and, after calling out and seeing the resident briefly look back and then continue walking, did not pursue the resident because the resident became agitated when her walking was interrupted. During this time, the door from Station 4 to the patio area was kept open to allow resident access, and the door lock was not activated until 8:00 p.m., allowing the resident to enter the patio area unsupervised. At approximately 7:00 p.m., another CNA found the resident alone on the ground in the Station 4 patio area, lying on the pavement and holding the back of her head. The responding LVN found the resident awake and alert, lying on the grass with slight bleeding at the back of the head and the front‑wheel walker tipped over nearby. Documentation in the change in condition progress note described a bump on the back of the head with slight bleeding and that the resident kept trying to get up unassisted during the nursing assessment before being assisted to a wheelchair and sent to the hospital. An LVN reported that the patio door was supposed to be alarmed but that the alarm had not worked for a long time and was not repaired until after the fall. The DON stated that primary safeguards for resident safety were hallway monitoring and coded/alarmed doors, and acknowledged that keeping the patio door open and not having staff present on the patio allowed the resident to go outside unsupervised, resulting in an unwitnessed fall.
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