Resident Elopement Due to Inadequate Supervision and Protocol Lapses
Penalty
Summary
The deficiency involved the failure of the Nursing Home Administrator and Director of Nursing to effectively manage the facility, resulting in a resident, identified as Resident R1, exiting the facility unsupervised. Resident R1, who had a history of repeated falls, difficulty walking, and cognitive communication deficit, was admitted to the facility with a care plan indicating the need for one-person staff assistance for ambulation. Despite this, Resident R1 was able to leave the facility without a physician order for leave of absence, which was not documented in the resident's records. On the day of the incident, a nursing assistant was informed by Resident R1 of the need to walk, but the assistant assumed it was within the unit. Later, the resident was found missing, prompting a Code Yellow for elopement. Surveillance footage showed Resident R1 leaving the facility behind a group of visitors, with the receptionist, Employee E9, failing to recognize the resident and allowing the exit without intervention. The receptionist was distracted by personal activities on the computer and did not follow the facility's protocol for visitor sign-out and badge return, contributing to the oversight. The resident was located 1.2 miles away in a busy urban area, having walked to a friend's apartment. The facility's investigation confirmed that the resident should not have been allowed to leave without supervision or a physician order. Interviews with facility staff, including the Regional Vice President of Operations, confirmed the non-compliance with leave of absence and visitation protocols, placing the resident at risk for serious injury. This situation was identified as an Immediate Jeopardy of past non-compliance.
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 or agreement with the deficiencies or conclusions contained in the Department's inspection report. Resident has been re-educated on the LOA on the process and is not currently at risk of elopement from the center. 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 NHS/DON respective job descriptions. The job descriptions state that they will maintain and develop written policies and procedures that govern the operations of the center to include Resident Leave of Absence, Wandering and Elopements Procedure - Missing Resident. RDO reviewed with LNHA and DON his/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 services department in accordance with the current federal, state, and local standards, guidelines and regulations that govern our center and as may be directed by the NHA and MD to ensure the highest degree of quality care is maintained at all times. The NHA and DON delegate the administrative authority, responsibility and accountability necessary for carrying out assigned duties. RDO will complete weekly audits for 12 weeks to ensure administrative enforcement of visitor badge process is being adhered to.