Failure to Ensure Safe Environment and Staff Training for Resident with Elopement Risk
Penalty
Summary
The facility failed to provide appropriate administrative oversight regarding clinical management and building safety, resulting in a resident with severe dementia and a known history of elopement falling from a second-floor window. The resident, who had previously attempted to elope from windows at other facilities and had demonstrated exit-seeking behaviors upon admission, was able to open a window in their bedroom that was not secured, leading to a fall that caused multiple fractures and required acute hospitalization. Staff had previously observed the resident attempting to open windows and doors, and had resorted to makeshift barricades, but no formal interventions were implemented to secure the windows or update the care plan after repeated elopement attempts. The facility's policies required assessment and prevention strategies for residents at risk of elopement, including securing the physical environment and providing staff training. However, the care plan for the resident did not include individualized interventions for window elopement, and the wander guard system in place only covered doors and elevators, not windows. Staff interviews revealed that incidents of attempted elopement through windows and doors were not communicated to management, and there was a lack of guidance or education provided to staff on managing such high-risk behaviors. Maintenance staff were aware that certain windows could open fully but did not document or address these safety risks, and the maintenance director relied on verbal confirmation rather than formal audits. Additionally, a review of employee records showed that most staff had not received required dementia or elopement risk training, and annual competencies were not completed. The facility assessment did not reflect the presence of residents with increased elopement risk or the need for specialized staff training in this area. The administrator and other leadership staff were unaware of the extent of the resident's elopement history and the lack of staff education, and there was no system in place to ensure that the environment was safe for residents with such behaviors.