Failure to Prevent Elopement, Implement Post-Fall Interventions, and Investigate Falls
Penalty
Summary
A severely cognitively impaired resident with a known history of wandering and elopement risk exited the facility unnoticed. The resident had previously demonstrated behaviors such as pacing, exit-seeking, and verbalizing intent to leave, and was identified as an elopement risk upon admission. Despite these known risks and documented interventions such as monitoring for tailgating, use of an audible monitoring system, and a departure alert device, the resident was able to leave the facility without staff awareness. Staff interviews confirmed that the resident was last seen in their room and was later found outside by a CNA who was returning from a break with another resident. There was no staff present with the resident at the time of elopement, and the incident was only discovered after the resident was observed outside, indicating a lapse in supervision and monitoring. Another resident, identified as high risk for falls due to a history of dizziness, hypotension, and previous falls, experienced a witnessed fall at the nurse's station, resulting in head injury and vomiting. The care plan for this resident included a neurology referral as a post-fall intervention, but as of the time of review, there was no documentation that a neurology appointment had been scheduled. Staff interviews confirmed that the resident had a pattern of sudden spells leading to falls, and that post-fall interventions were not fully implemented as documented in the care plan. A third resident with severe cognitive impairment and a history of falls reported falling out of bed and sustaining a skin tear and swelling to the left elbow. The facility's investigation into this incident was incomplete, lacking staff interviews or statements regarding the fall or injury. The care plan included interventions such as a prompted toileting program and a scoop mattress, but there was no documentation of when the resident was last toileted on the day of the fall. The lack of thorough investigation and documentation limited the facility's ability to identify the circumstances of the fall and implement appropriate interventions.