Failure to Prevent Accidents and Elopement Due to Inadequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with cognitive impairment and high risk for elopement and injury. One resident, with a history of dementia, seizure disorder, and behavioral symptoms including aggression and elopement attempts, was placed on 1:1 supervision for safety. Despite this, there were documented gaps in 1:1 supervision, including periods where no staff were present to monitor the resident. During one such period, the resident exhibited altered mental status, was found with bloody drainage from the ear, and was later diagnosed at the hospital with a right temporal hemorrhagic contusion, temporal bone fracture, and epidural hematoma. Staff interviews and documentation confirmed lapses in supervision and incomplete handoff between shifts, contributing to the resident's harm. Another resident with moderate to severe cognitive impairment and a history of wandering was care planned to wear a wander guard device. The resident repeatedly removed the device, and there were multiple documented instances where the device was not in place. The facility failed to reassess the resident's elopement risk after significant changes in condition and after the resident was assigned a legal guardian due to incapacity. The resident ultimately eloped from the facility through an alarmed front door, remaining unsupervised outside for approximately 50 minutes before being located and returned by police. Staff interviews revealed that the door alarm system did not function as intended, and the wander guard device did not reliably trigger the alarm or lock the door as required. Facility policies required continuous supervision for residents on 1:1 monitoring and regular checks of wander guard devices, but these were not consistently followed. Documentation and staff statements indicated that assigned staff were not always present, handoffs were incomplete, and monitoring tools were not properly utilized. The combination of inadequate supervision, failure to reassess risk, and malfunctioning safety equipment directly contributed to the residents' exposure to harm and, in one case, actual injury.