Failure to Prevent Resident Elopement and Inadequate Fire Safety Response
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for its residents. One resident with severe cognitive impairment and a history of wandering and elopement was moved from a secured, code-locked unit to a less secure unit. Despite documented high risk for elopement and repeated nursing notes indicating increased wandering behaviors, the resident was not consistently provided with a wander guard as ordered. The Treatment Administration Record showed that the wander guard was not in place for several days prior to the resident's elopement, and there was no documentation that the clinical team was notified of the missing device. The resident subsequently eloped from the facility and was missing for four hours before being found by police. Interviews with facility staff, including the Unit Manager, Assistant DON, and DON, revealed a lack of awareness regarding the resident's increased elopement risk and the absence of the wander guard. The decision to move the resident was based on the perception that the resident was doing better and needed more activity participation, despite ongoing documentation of high elopement risk. The staff failed to communicate changes in the resident's behavior and the missing wander guard, resulting in inadequate supervision and a failure to implement necessary interventions. Additionally, the facility did not respond appropriately to an open flame fire in the kitchen during breakfast service. Surveyors observed multiple instances where a conveyor toaster caught fire, producing open flames and smoke, while dietary staff left the appliance unattended. Staff attempted to remove burning food with metal tongs without unplugging the toaster and failed to notify supervisors or follow fire safety protocols. Items were also improperly stored on top of the hot toaster, increasing the risk of fire. Interviews with dietary staff and the Food Service Director confirmed a lack of adherence to fire safety procedures and inadequate response to the fire incidents.