Failure to Prevent Accident Hazard Due to Inadequate Supervision of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with cognitive impairment, alcohol-induced dementia, and a court-appointed guardian was not provided with effective supervision, resulting in a serious incident. The resident, who had a history of confusion, agitation, and impaired judgment, was allowed unsupervised access to an enclosed courtyard where he was considered a safe smoker. On the day of the incident, the resident became upset after being told by staff that he would be moved to a secured unit. Subsequently, he stacked patio furniture, climbed onto an awning, and then accessed the facility's roof. Staff observed the resident running and sitting on the edge of the roof, prompting the fire department to be called for his safe removal. Prior to this event, the resident had not exhibited wandering or exit-seeking behaviors, but staff had noted increased agitation and unsafe behaviors, including attempts to take his non-smoking roommate outside to smoke. Despite these observations and discussions with the guardian about escalating behaviors and the potential need for a higher level of care, the resident remained in the unsecured unit. The resident's care plan had not been updated to reflect the increased risk, and he was not placed under enhanced supervision or restricted from unsupervised courtyard access until after the incident occurred. Additionally, the facility failed to complete a smoking assessment on admission and quarterly for another resident to determine if independent smoking was safe or if supervision was required. The lack of timely reassessment and supervision for residents with cognitive impairment and behavioral changes contributed to the occurrence of the incident and the identified deficiency.
Removal Plan
- Resident #120 was placed on enhanced supervision and restricted from unsupervised courtyard access after the incident.
- Resident #120 was reassessed and changed from a safe smoker to a supervised smoker.
- Resident #120 was relocated to a room closer to the nurses' station for increased observation.
- All residents with cognitive deficits and physical capabilities were assessed for wandering, change in behavior, increased agitation, and problematic behaviors.
- Wander guard transmitters were placed on all residents identified as having the ability to wander.
- The Interdisciplinary Team reviewed all residents to identify those with wandering or exit-seeking behavior.
- Staff members were assigned as wandering resident monitors on duty to monitor wandering residents and points of egress.
- All staff received in-service training on supervision of wandering residents, continuous observation, escalation of concerns, and environmental risk identification.
- Staff were instructed to relocate residents displaying exit-seeking or wandering behavior to the secure unit and notify the DON for evaluation.
- All employees were re-hired by new ownership and required to complete dementia and behavior management training to be eligible for rehire.
- All new hires receive training on dementia and care of wandering/behavioral residents during orientation and thereafter.
- Unsupervised courtyard access was restricted for residents with wandering or unsafe behaviors.
- Designated staff monitor the courtyard during resident use.
- Routine environmental rounds are conducted to identify elevated surfaces and climbing risks.
- Behavioral escalation triggers are incorporated into care planning.
- Nurse managers are to be notified immediately for new agitation, pacing, wandering, or exit-seeking behavior; a wandering assessment is completed, wander guard placed, provider and responsible party notified, and care plan updated.
- Residents with new wandering or exit-seeking behaviors are discussed in clinical meetings.
- The DON is responsible for ensuring wandering assessments, notifications, wander guard initiation, and care plan updates are completed.
- A list of exit-seeking/wandering residents is updated and reviewed by the DON and Social Worker.
- Resident wandering assessments and nursing documentation are audited by the DON/ADON to identify residents with increased agitation, exit-seeking, or wandering behavior.
- Audits ensure residents with these behaviors have wander guards and appropriate care plan interventions.
- Audit results are discussed at the clinical At-Risk IDT Meeting and presented to the QAPI Committee for review and revision as needed.
- All residents are assessed for wandering and exit-seeking and with any significant change in condition.
- Education on facility processes for residents with increased agitation, pacing, exit-seeking, or wandering behavior is provided to all staff and reviewed.
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