Failure to Supervise and Assess Residents at Risk for Elopement and Falls
Penalty
Summary
The facility failed to provide adequate supervision and accurate assessment for residents at risk of elopement and falls, resulting in a significant incident where a resident exited the facility unsupervised and sustained a serious injury. The resident, who had a history of adjustment disorder, insomnia, depression, moderate dementia, repeated falls, anxiety disorder, and unsteadiness, was assessed as being at risk for both elopement and falls. Despite this, the resident did not have an elopement care plan in place, and staff failed to implement or escalate interventions after the resident was previously found outside the facility near exit doors. Documentation indicated that staff were aware of the resident's wandering and exit-seeking behaviors, but communication breakdowns and lack of timely review of progress notes led to missed opportunities for intervention. On the night of the incident, the resident was found outside the facility by a bystander, having fallen from their wheelchair and sustaining a right elbow fracture that required hospital admission. Staff interviews revealed that the resident was able to self-propel in a wheelchair and had previously been redirected from exit doors, but no effective measures such as a wanderguard or increased supervision were put in place prior to the elopement. The door used by the resident was not alarmed unless a wanderguard was present, and the resident did not have one at the time. Staff responsible for reviewing progress notes and implementing interventions did not act on documented concerns, and the resident's risk was not properly communicated or addressed in care planning. Further review of other residents at risk for elopement revealed similar deficiencies in assessment accuracy, identification in the facility's elopement risk book, and monitoring interventions. Several residents with multiple diagnoses of dementia or mental illness had their elopement risk scores calculated incorrectly, resulting in under-identification of risk. Additionally, residents with documented need for wanderguards did not have corresponding physician orders for monitoring placement and function, and staff were often unaware of which residents had these devices. The facility's failure to follow its own policies for assessment, care planning, and supervision placed multiple residents at risk for elopement, falls, and injury.