Failure to Complete Elopement and Smoking Risk Assessments
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, specifically in the areas of elopement and smoking risk assessment. One resident with diagnoses including dementia, diabetes, and major depressive disorder exhibited repeated wandering and exit-seeking behaviors, including packing belongings and attempting to leave the facility. On two separate occasions, the resident was able to exit or attempt to exit the building, once following EMS out the front doors and another time through a propped-open smoking door. Despite these incidents and the resident's history of wandering, an elopement risk assessment was not completed after the first occurrence, and interventions were not implemented until after the second incident. Staff interviews confirmed that the resident regularly attempted to leave the building and that staff were aware of her behaviors. The LPN and housekeeper both described the resident's repeated efforts to exit, with the housekeeper discovering the resident outside the facility property during one incident. The administrator acknowledged that an elopement assessment and care plan should have been completed after the initial event but were not, and the nurse consultant confirmed that assessments should occur after such attempts or significant changes. In a separate case, another resident with a history of tobacco use and multiple medical conditions, including nicotine dependence, was identified as a smoker. However, the required smoking risk assessment and care plan were not completed until after the resident was observed smoking in the designated area. Staff interviews revealed that the resident was 'grandfathered in' to smoke at the facility, but the necessary documentation and assessment were missing from the electronic health record until after the deficiency was identified. The MDS coordinator confirmed that the assessment and care plan should have been in place but were not completed until after the oversight was discovered.