Inadequate Supervision and Dietary Non-Compliance
Penalty
Summary
The facility failed to provide adequate supervision for two residents, resulting in elopement incidents. Resident R42, who has severe cognitive impairment due to dementia and Parkinson's disease, was able to exit the facility unsupervised on two occasions. Despite being seen outside in the snow without a coat, the facility did not document an assessment upon his return or notify the physician. The Director of Nursing and Nursing Home Administrator did not initially treat these incidents as elopements, as they believed the resident had the right to be in the courtyard, although there was no documentation of supervision. Another resident, R114, who had expressed a desire to leave against medical advice, managed to leave the facility via a ride service without staff knowledge. The facility was unaware of the resident's absence until the following morning and initially categorized the incident as an AMA discharge rather than an elopement. This oversight indicates a lack of adequate supervision and monitoring of residents who are at risk of leaving the facility without authorization. Additionally, the facility failed to follow a prescribed diet order for Resident R50, who was on an NPO diet due to severe aspiration risk. Despite physician orders and speech therapy recommendations, the resident was given fluids by staff members, and the resident's mother provided additional fluids and soups. This failure to adhere to dietary restrictions posed a significant risk to the resident's health, as the facility did not ensure compliance with the prescribed diet order.
Plan Of Correction
Resident R42 remains at the facility and suffered no negative outcomes as a result of his elopements. Resident R114 did not return to the facility and the facility was not notified of any negative outcomes as a result of leaving via UBER ride service. Resident R50 was transferred to the hospital for unrelated health issues and will not be returning to the facility. The facility has installed magnetic alarms at the facility front entrance to alert staff of anyone opening the emergency release when the doors are locked, or a receptionist is not present. The courtyard doors are now to be locked at all times for temps below 50 degrees unless a staff member is present for supervision of any cognitively impaired residents. The facility will install wander guard systems on the courtyard doors. All staff will be educated by the NHA or designee on elopement and required supervision, and courtyard use. All Direct care staff will be educated in following prescribed diet orders. The DON or designee will audit all incidents for elopements and failing to follow prescribed physician orders. All NPO residents will be audited once a week to ensure that physician orders are followed. Courtyard doors will be audited daily to ensure they always remain locked while awaiting wander guard installation. Results will be reviewed through QAPI for further recommendation.