Failure to Prevent Elopement and Ensure Safety for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with cognitive impairments and a history of wandering. Both residents had physician orders and care plans requiring the use of Wander Guard devices, with checks for placement and functionality to be performed and documented every shift. However, multiple instances were identified where these checks were not documented for both residents across several shifts, as confirmed by the Director of Nursing (DON) and review of the Medication Administration Records (MARs). The DON acknowledged that facility policy was not followed regarding these required checks. Additionally, the facility did not complete required elopement risk assessments for the two residents on a quarterly basis, as stipulated by facility policy and confirmed by the DON. One resident had not been reassessed for elopement risk since admission, and the other had not been reassessed since a previous quarterly assessment, despite both being identified as high risk for elopement. After one resident exited the facility unsupervised and was found in the street, there was no documentation of a change in condition, no care plan update, and no reassessment for elopement risk, contrary to facility policy. The incident involving the resident who exited the facility revealed further lapses in supervision and documentation. Staff interviews confirmed that the resident was found outside by a staff member, but it was unclear how long the resident had been outside or how the exit occurred. There was no documentation in the electronic medical record regarding the incident, and the required follow-up assessments and documentation were not completed. Furthermore, the Maintenance Supervisor reported that weekly checks of the Wander Guard system were performed but not documented, which was inconsistent with best practices and manufacturer recommendations.