Failure to Supervise Elopement-Risk Resident Results in Serious Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, multiple sclerosis, bipolar disorder, and dementia, who was assessed as an elopement risk, was inadequately supervised. The resident was known to require extensive assistance for transfers and had a care plan in place that included interventions such as a Wander Alert device, an air tag, and staff education to prevent entry into restricted areas. Despite these measures, the resident was able to independently operate a power wheelchair and access a non-residential area of the facility. On the day of the incident, the resident was last seen in the dining room and later in a hallway, where staff instructed the resident to return to their unit. Subsequently, the resident could not be located, and staff initiated a search throughout the facility. The resident was missing for approximately four hours before being found at the bottom of a stairwell, still strapped into the wheelchair, after having fallen down a flight of stairs. The door to the stairwell had been left open accidentally, and there was no alarm or security device on the door, as it was not considered part of the resident area. The resident sustained multiple serious injuries, including rib fractures, a clavicle fracture, a subdural hematoma, a pneumothorax, a finger dislocation, and a scalp laceration requiring stitches. The incident was confirmed through staff interviews, clinical documentation, and hospital records. The failure to provide adequate supervision and to secure non-residential areas directly led to the resident's prolonged absence and subsequent injuries.
Removal Plan
- Assess the safety of residents utilizing power wheelchairs.
- Facility assessment for resident safety with use of power wheelchairs was completed.
- Facility identified five residents that are at potential at risk based on the completed audit.
- Resident R1 was assessed upon his return from hospitalization by rehabilitation services.
- Resident R1 was set up for manual wheelchair for safety.
- Ensure all doors are locked to non-resident areas.
- Set up of keypad lock to Morris Building to limit resident access to non-residential area.
- Education of staff that was responsible for non-compliant with security door process.
- Updated security process to monitor and audit identified doors to non-residential areas to ensure resident safety.
- Revise/ review resident safety policies to include power wheelchairs, locked doors, stairwells, and elopements.
- Facility review of resident safety policy initiated.
- Ensure development of care plan interventions to prevent residents from entering non-resident areas.
- Care plan for identified residents at risk were updated based on facility audit.
- Resident R1's care plan was updated upon return from hospitalization.
- Ensure doors are functioning properly and staff are in-serviced on areas in the building where residents are restricted related to resident safety.
- Ongoing security department monitoring and audit of identified doors to ensure that the doors are secured and functioning properly.
- Provide staff training on ensuring residents don't enter areas of the building where residents are restricted from being related to resident safety.
- Inglis House staff training on ensuring residents don't enter areas of the building where residents are restricted from related to resident safety started and is ongoing.
- Facility has completed approximately 50 percent of the training and is expected to complete 100 percent compliance.