Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident from a locked unit, which resulted in an immediate jeopardy situation for all 461 residents. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were found to have not effectively managed the facility to prevent this incident. The job descriptions for both the NHA and the DON clearly outline their responsibilities to manage the facility in accordance with federal, state, and local standards and to ensure the highest degree of quality care is provided to residents. However, their failure to fulfill these essential duties led to the elopement incident. The report highlights that the NHA and DON were notified of their failure to manage the facility effectively, which created an immediate jeopardy situation. The specific regulations cited include the responsibility of the licensee, management, and the administrator's responsibility, as well as nursing services. The deficiency was identified through a review of job descriptions, clinical records, and staff interviews, indicating a systemic failure in the administration and nursing services to adhere to required guidelines and regulations.
Plan Of Correction
1. Assessments and care plans were reassessed by the nursing department for all residents to ensure accurate identification of elopement risk. All employees were re-inserviced by nursing administration on proper assessment and care-planning to identify elopement-like behaviors. 2. The NHA and Director of Nurses were re-inserviced by Core Tactics consulting firm representative on elopement risk and policy and procedure and their respective job descriptions to ensure residents were free from the risk of elopement. 3. The NHA and Director of Nursing audit monthly for three months following initial daily audit x 30 days to ensure residents at risk for elopement have an assessment and care plan for elopement risk.