Failure to Prevent Elopement and Inadequate Supervision for Residents at Risk of Accidents
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for two residents. One resident, with diagnoses including Parkinson’s disease, metabolic encephalopathy, and a history of hallucinations and wandering, was identified as an elopement risk. Despite being assessed as high risk for elopement and having interventions such as a wander alert device and room relocation, the resident was able to exit the building unsupervised on at least two occasions. Staff interviews revealed confusion about responsibilities for monitoring wander alert devices, inconsistent use and checking of the devices, and lack of proper documentation of elopement incidents in the resident’s medical record. The facility also lacked a systematic approach to ensure that all exit doors were properly alarmed and that alarms were audible to staff, with maintenance checks being inconsistently documented and no plan for checks during off-hours. Another resident, who was cognitively intact but had reduced mobility and required supervision and a gait belt when ambulating, was repeatedly observed walking unassisted in the hallway with a walker and without a gait belt. Staff were not consistently providing the required supervision, and there was a lack of direct observation during ambulation. Interviews with staff indicated a lack of awareness of the resident’s current care plan requirements, with some staff believing the resident was independent based on observation rather than documented care plans or therapy recommendations. The care plan and Kardex specified that the resident required stand-by assistance and a gait belt, but this was not consistently followed. Communication breakdowns between therapy, nursing, and direct care staff contributed to the deficiencies. Therapy staff reported challenges in ensuring that updated transfer and ambulation status information was communicated to nursing staff, and nursing staff reported that care plan changes were not always effectively communicated. Staff turnover and unclear assignment of responsibilities for safety device checks further contributed to the lack of consistent supervision and hazard mitigation for residents at risk of accidents or elopement.