Failure to Prevent Elopement and Document Falls
Penalty
Summary
The facility failed to prevent elopement and document falls for multiple residents, resulting in deficiencies related to supervision and accident prevention. One resident with moderate cognitive impairment and a history of falls was able to leave the facility unsupervised and was found walking down the road by a visitor, who notified staff. The resident was picked up by a CNA and returned to the facility, but there was no documentation of the elopement in the resident's health record, and staff were unclear about which residents were at risk for elopement. Another resident, identified as high risk for elopement and with a history of schizo-affective disorder, was able to leave the facility without staff knowledge and was found three miles away on a state highway in a construction zone by an off-duty staff member. This resident had previously attempted to elope multiple times and was returned to the facility covered in mud and fecal matter, but again, there was no documentation of the elopement in the health record. Staff interviews revealed confusion and inconsistency regarding the identification and supervision of residents at risk for elopement. Some staff relied on verbal communication from charge nurses to determine which residents could leave unsupervised, while others were unaware of any formal assessment or list. The DON and administrator were not notified of the elopements, and there was no documentation or incident reporting for these events. The care plans for residents at risk for elopement did not include appropriate interventions to prevent elopement, and staff were not consistently aware of or following facility policy regarding elopement prevention and response. Additionally, the facility failed to document an unwitnessed fall for another resident with a history of traumatic brain injury and dementia. An anonymous email with a photo showed the resident on the floor, but there was no documentation of the fall in the health record. The charge nurse admitted to finding the resident on the floor and assessing them but did not document the incident, mistakenly believing the resident was care planned to be on the floor. These failures in supervision, documentation, and communication contributed to the deficiencies cited by surveyors.