Failure to Provide Adequate Supervision and Monitoring Leads to Resident Elopement and Injury
Penalty
Summary
A resident with a history of cognitive impairment, dysphagia, and previous elopement was not provided with adequate supervision and monitoring as required by their care plan and physician orders. The resident was identified as being at risk for aspiration, falls, and elopement, with care plans and physician orders specifying interventions such as supervision during meals, frequent visual checks, and placement near the nursing station. Despite these documented risks and interventions, staff failed to consistently implement and document the required supervision and monitoring. For example, the resident was left unsupervised during mealtimes, and staff were unaware of the supervision order. Documentation of meal intake and visual checks was inaccurate or completed without direct observation of the resident. On the day of the incident, the resident was last seen in their room before lunch, but was not visually confirmed to be present by the assigned CNA, who assumed the resident was in the bathroom and documented meal intake without verifying the resident's presence or consumption. The nurse assigned to the resident did not perform the required blood pressure checks or visual monitoring as ordered, and used earlier readings to fill documentation. During shift change, handoff procedures were insufficient, with staff not being informed of the resident's elopement risk or previous incidents. As a result, the resident's absence went unnoticed for several hours, and staff only became aware the resident was missing during the evening meal service. The resident was later found in the community after having eloped from the facility, suffering a fall and requiring hospital evaluation for trauma and aspiration precautions. Interviews with staff revealed a lack of awareness regarding the resident's elopement risk, required supervision, and the need for individualized care plan interventions. The care plan for elopement was not person-centered and did not include specific interventions such as visual checks or supervision. The failure to implement and communicate required safety interventions, combined with inadequate handoff and documentation practices, directly contributed to the resident's elopement and subsequent injury.