Failure to Prevent Elopement and Repeated Falls Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for two residents, resulting in deficiencies related to elopement and repeated falls. One resident with a history of cognitive impairment, communication deficits, and a public fiduciary was admitted without a completed cognitive assessment or care plan addressing his impaired cognition. Despite documentation from hospital records and therapy evaluations indicating cognitive impairment and the need for a guardian, the facility did not initiate interventions to mitigate risks associated with his condition. The resident was found ambulating alone on the street on two separate occasions, with staff only implementing a wander guard and behavioral care plan after these incidents. There was no evidence of a timely wandering risk evaluation, supervision/monitoring logs, or an investigation file for the elopement events, contrary to facility policy requirements. Another resident, re-admitted with diagnoses including Parkinson's disease, traumatic brain injury, dementia, and abnormal gait, experienced multiple falls shortly after admission. The resident's care plan was not updated with new interventions for an extended period despite repeated falls, and there was no evidence of neuro check logs during the admission period. Documentation revealed the resident was highly confused, unable to use the call light, and required frequent monitoring and 1:1 supervision at times, but the facility did not consistently implement or document these interventions. Staff interviews confirmed that care plan updates and supervision were lacking during a period of repeated falls, and that the facility did not employ 1:1 supervision due to staffing limitations, even when it was indicated as necessary. Facility policies required prompt assessment, documentation, and investigation of accidents and incidents, as well as individualized fall prevention plans and immediate safety strategies for residents with cognitive or behavioral risks. However, the facility did not follow these protocols for the residents in question, as evidenced by missing assessments, incomplete care plans, lack of documentation, and failure to implement or document appropriate interventions after repeated incidents. These actions and omissions resulted in residents being exposed to preventable accidents and inadequate supervision.