Failure to Prevent Elopement and Inconsistent Fall Prevention Measures
Penalty
Summary
The facility failed to follow its own policies regarding fall prevention and elopement, resulting in deficiencies related to accident hazards and inadequate supervision. In one instance, a resident with a history of hydrocephalus, dementia, and other medical conditions was able to leave the facility without authorization during the night. Staff last observed the resident in bed during routine checks, but later discovered the resident missing after an alarm sounded. The nurse on duty was unfamiliar with the alarm system and did not immediately recognize the significance of the alarm sounds, delaying the response. The resident was eventually found outside the facility by police and returned unharmed. Interviews revealed that not all staff were clear on the alarm system's operation or had participated in elopement drills as required by facility policy. In another case, a resident with severe cognitive impairment and multiple risk factors for falls experienced an unwitnessed fall. The resident was found on the floor by staff during a midnight round and was unable to be oriented to reality. Documentation showed that the physician was not notified of the fall until more than 24 hours after the incident, contrary to facility policy which requires immediate notification. Additionally, the resident's care plan included the use of floor mats as a fall intervention, but observations revealed inconsistent implementation of this intervention. The resident's family member reported having to place a floor mat herself, indicating lapses in staff adherence to the care plan. These events demonstrate that the facility did not consistently implement or monitor required interventions for fall prevention and elopement risk. Staff interviews highlighted gaps in knowledge and training regarding emergency procedures and the use of safety equipment. The lack of timely physician notification and inconsistent application of care plan interventions contributed to the deficiencies identified during the survey.