Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The deficiency involved the failure of the Nursing Home Administrator and Director of Nursing to effectively manage the facility, resulting in inadequate supervision of a resident at risk for elopement. The resident, who had a history of stroke, schizophrenia with prior psychosis, and cognitive dysfunction, was admitted to the facility and identified as being at risk for elopement. Despite the development of an elopement care plan, the resident managed to exit the facility and was missing for over 24 hours. The resident was last seen by staff in the afternoon and was discovered missing later that evening. The facility's search efforts were unsuccessful, and the resident was eventually located at another center 2.2 miles away, in a busy urban area. The resident was returned to the facility and assessed for respiratory concerns, which required a visit to the emergency room. Upon return, the resident was placed under one-to-one supervision. Interviews with staff revealed that a wander guard was applied to the resident upon admission, but there was no documented order for it, nor evidence that it was tested for functionality. The facility lacked a tester box to verify the wander guard's operation, which was on order. This oversight contributed to the resident's ability to elope, highlighting a significant lapse in the facility's management and adherence to federal and state guidelines.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. Resident has been assessed and identified as elopement risk. Resident is being maintained on 1:1 supervision 24/7. A full house audit was completed to identify any other residents similarly affected. All variances were updated and discussed with the physician. Care plans were updated to address safety and supervision. RDO reviewed with the NHA his respective job description that includes "Equipment and Supply Function" section stated that the NHA are to ensure that the Center is maintained in a clean and safe manner for residents' comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services. Ensure that adequate supplies and equipment are on hand to meet the day-to-day operations needs of the Center and residents. NHA reviewed with DON her respective job description which includes that the purpose of the position was to plan, organize, develop and direct the overall operation of the nursing service department in accordance with current federal, state and local standards, guidelines and regulations that govern our Center and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. The Director of Nursing Services delegates the administrative authority, responsibility and accountability necessary for carrying out assigned duties.