Failure to Supervise Elopement Risk Resident Results in Serious Injury
Penalty
Summary
The facility failed to provide adequate supervision and management for a resident identified as being at risk for elopement, resulting in a serious incident. The Nursing Home Administrator (NHA) and Director of Nursing (DON) did not ensure that appropriate safety measures were in place or that staff were adequately monitoring the resident. The resident, who had a history of severe cognitive impairment, multiple sclerosis, bipolar disorder, and dementia, was known to be at risk for elopement and had interventions in place such as a Wander Alert and an air tag. Despite these interventions, the resident was able to move independently in a power wheelchair and access a restricted area of the facility that was not properly secured or monitored. On the day of the incident, the resident was last seen in the dining room and later observed wandering in a different area of the facility. Staff became aware that the resident was missing after an unsuccessful search of the unit and other accessible areas. Security measures, such as the Roam alert, did not activate, and staff were unable to locate the resident for several hours. Eventually, the resident was found at the bottom of a stairwell, having fallen down a flight of stairs while still strapped into the wheelchair. The door to the stairwell had been left open and was not equipped with a wanderguard detector, allowing the resident to access the area without triggering an alarm. As a result of the fall, the resident sustained multiple serious injuries, including rib fractures, a fractured clavicle, a subdural hematoma, a pneumothorax, a finger dislocation, and a scalp laceration requiring stitches. The incident was classified as Immediate Jeopardy Past Noncompliance due to the failure of the NHA and DON to fulfill their responsibilities in ensuring resident safety and compliance with federal and state regulations. The lack of effective supervision, inadequate environmental controls, and failure to follow established care plan interventions directly contributed to the resident's injuries.
Plan Of Correction
NHA and DON reviewed their job descriptions and duties of the administrator and Director of Nursing with the president and CEO of Inglis. There are no like instances. Education to DON and Administrator was completed by the CEO of Inglis. Job descriptions will be reviewed annually.