Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
A resident with a history of unsteadiness, substance abuse, and smoking was able to leave the facility unsupervised late at night. The resident was not located by staff for approximately 14 hours and was later found with injuries, including abrasions to the face and a swollen, scraped knee, after falling from a wheelchair while away from the facility. The resident reported being lost and unable to find the way back, and required medical evaluation and wound care upon return. The facility's records indicated that the resident was at moderate to high risk for falls, but the fall risk assessments did not account for the antihypertensive medication the resident had been taking, which could have increased the risk. The care plans for substance abuse and smoking included interventions such as assessing the risk of leaving the facility without notification and providing supervision while smoking. However, these interventions were not effectively implemented, as the resident was not accompanied outside and was able to leave the premises without staff awareness. Staff interviews revealed that the licensed nurse on duty was aware the resident had left but did not report the incident until shift change, following advice from a senior nurse to wait until morning to notify the DON and police. There was no immediate search or notification to security or supervisors during the night, and the facility was unable to provide a policy ensuring supervision of residents while smoking. These actions and inactions resulted in the resident's elopement and subsequent injury.