Failure to Prevent Resident Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The Nursing Home Administrator and Director of Nursing did not effectively manage the facility to ensure that necessary care and services were provided to residents requiring adequate supervision to prevent elopement. Review of job descriptions, clinical records, and staff interviews revealed that the facility failed to maintain necessary supervision and implement person-centered care plan interventions, resulting in two residents exiting to unsupervised or unauthorized areas without the facility's knowledge. This failure constituted an immediate jeopardy situation for two of the 21 residents identified as at risk for elopement. The facility did not ensure that residents received treatment and care in accordance with professional standards of practice, facility policies, physician orders, and the comprehensive person-centered policy.