Failure to Provide Required 1:1 Supervision for Resident with Elopement Risk
Penalty
Summary
The facility failed to follow the care plan for a resident with a history of elopement, impaired safety awareness, and multiple behavioral issues related to dementia and neurological conditions. The resident's care plan required 1:1 supervision at all times due to risks of wandering, elopement, and communication difficulties. Despite this, a hospitality aide assigned to the resident left the room for a break without ensuring another staff member was present to maintain supervision. As a result, the resident was left unattended and subsequently wandered from his room into another resident's room. Record reviews confirmed that the hospitality aide's job description required understanding and carrying out resident care plans, and the resident's care plan specifically mandated continuous 1:1 supervision. Interviews with the Director of Nursing confirmed that the facility did not have an appropriate care plan policy and that staff did not follow the established care plan or job expectations. The incident occurred when the hospitality aide failed to arrange for coverage during their absence, and the registered nurse did not provide the required supervision, leading to the resident's unsupervised wandering.