Abundant Living # 2

The facility failed to ensure that three exit doors accessible to a disoriented resident had working alarms that were audible to staff. Observations revealed that some alarms were turned off or were improperly installed, allowing residents to exit the building without triggering an alert.

The facility failed to maintain functional door alarms on multiple entrance and exit points, allowing residents to exit the building without an audible alert. Specifically, the front door alarm was turned off, and the alarms on the side doors were missing necessary components to activate. This lack of monitoring allowed residents, including those with cognitive impairments, to wander outside unsupervised.

The facility failed to ensure that three exit doors accessible to residents at risk of wandering were equipped with functioning, audible alarms of sufficient volume. This failure resulted in one resident wandering away from the facility.

The facility failed to ensure that three exit doors accessible to residents known to be disoriented were equipped with working alarms of sufficient volume. Observations revealed no alarms sounded when doors were opened and closed, which resulted in a resident wandering away from the facility.

The facility failed to ensure that staff members were competency validated to perform licensed health professional support (LHPS) tasks. Specifically, three sampled staff members had not completed competency validation for the application and removal of thrombo-embolic deterrent (TED) hose, despite orders being in place for a resident.

The facility failed to ensure that three sampled staff members had completed competency validation for the Licensed Health Professional Support (LHPS) task of applying and removing thrombo-embolic deterrent (TED) hose. Record reviews and interviews confirmed that staff members were performing these tasks without the required validated competency from a licensed health professional.

The facility failed to ensure that 3 of 3 sampled residents had a completed assessment and care plan within 30 days of admission or updated annually. Specifically, Resident #1 lacked a dated and physician-signed care plan, and Resident #2's care plan had not been updated since October 2019.