Failure to Provide Adequate Staffing Resulting in Resident Elopement
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the supervision needs of a resident with Alzheimer's dementia, resulting in the resident eloping from the facility. On the day of the incident, staffing records show that only one CNA was present on the first floor at times between 4 PM and 5 PM, as another CNA was on a lunch break, the agency LPN was on break outside the facility, and the float CNA was working on the second floor. During this period, the resident eloped, and the wander guard alarm at the front door was triggered. Staff conducted a head count and room checks but were unable to locate the resident, eventually finding the resident's monitoring device discarded in a trash can by the front door. The resident was found approximately a mile away from the facility in a ditch along a busy road, with grass-stained and wet clothing and a cut on his arm, indicating he had fallen during the elopement. Interviews with staff and the resident's wife revealed that the facility was short-staffed, particularly on the evening shift and weekends, and that staff were unable to complete required 15-minute checks for the resident due to insufficient staffing. The resident's wife reported being told by staff that the facility did not have enough help to provide one-on-one supervision or close monitoring for the resident, and she felt pressured to take him home for the weekend as a result. Staff statements confirmed that breaks were taken simultaneously by key personnel, leaving only one CNA on the floor during a critical period. The administrator acknowledged that there was no formal staffing policy and was unaware that both the agency nurse and a CNA were on break at the same time. Multiple staff members expressed concerns about inadequate staffing levels and the challenges of supervising residents with high needs, such as those at risk for falls or elopement, when staffing was insufficient.