Failure to Provide Adequate Supervision and Accident Hazard Prevention for Residents at Risk of Elopement
Penalty
Summary
The facility failed to provide adequate supervision and accident hazard prevention for two residents identified as being at risk for elopement. One resident, who had moderately impaired cognition and required a walker for mobility, was able to leave the facility undetected for approximately one hour despite wearing a wander guard. The resident exited through the locked front entrance, which was opened by an unknown responsible party with access to the door code. Staff were unaware of the resident's absence until notified by community members, and documentation revealed that required 15-minute safety checks were not completed as directed in the care plan. Interviews with staff indicated a lack of communication and training regarding elopement risks and required supervision. The nurse assigned to the resident was not aware of the need for 15-minute checks, and agency staff did not receive adequate orientation or access to care plans prior to their shifts. The resident was able to leave the facility by following a transportation driver out the door, and staff did not notice the resident's absence until contacted by external parties. The facility's internal investigation confirmed that staff were the only individuals with knowledge of the door code, and no staff admitted to allowing the resident to exit. A second resident, also identified as an elopement risk, was observed being allowed to exit the facility by a dietary staff member who was unaware of the resident's supervision requirements. The dietary staff member used the door code to let the resident outside, and the door alarm sounded, but the staff member did not respond appropriately. The DON confirmed that non-nursing staff did not have access to care plans and relied on verbal communication from supervisors to identify residents at risk for elopement. Facility policy required vigilant supervision and a systemic approach to monitoring residents at risk for elopement, but these procedures were not effectively implemented.