Failure to Prevent Elopement and Ensure Safe Transfer Techniques
Penalty
Summary
The facility failed to ensure adequate supervision and implement safety interventions to prevent accidents for two residents. In the first incident, a resident with Parkinson's disease, dementia, and a history of hallucinations exited the facility unsupervised through an exit door that triggered an alarm. Staff did not immediately investigate the alarm, assuming it was malfunctioning, and did not conduct a room-to-room check to account for all residents. The resident was found outside in the parking lot by a dietary staff member approximately 30 minutes later, appearing confused, tired, and reporting feeling threatened by a nurse. Multiple interviews confirmed that staff heard the alarm but did not respond appropriately, and some staff were unfamiliar with the facility's policies regarding alarms and elopement. In the second incident, another resident with a right femur fracture and a care plan requiring a stand-assist mechanical lift was manually transferred by two CNAs without the use of the required lift. During the transfer, the resident's foot became caught under the wheelchair, resulting in a right ankle sprain. The CNAs involved were agency staff who did not provide a reason for not using the mechanical lift, despite the resident's care plan and room signage indicating its necessity. The resident reported that the lift was available in the room at the time of transfer, and she did not refuse its use. The incident was later reported to therapy staff, and the resident was unable to fully participate in physical therapy for several weeks due to the injury. Interviews with facility staff, including the DON and care plan nurse, confirmed that the use of a mechanical lift was required for the resident and that CNAs are not permitted to determine lift methods. The facility's policy allows for manual transfers only in specific circumstances, such as emergencies or mechanical failure, but no such exception was documented for this incident. The charge nurse also confirmed that the facility operates as a no-manual-lift environment and that the CNAs did not provide justification for their actions.