Failure to Prevent Resident Elopement and Bed Fall Due to Inadequate Supervision and Identification Systems
Penalty
Summary
A resident with severe cognitive impairment and significant physical limitations was re-admitted to the facility and required substantial assistance for mobility and incontinence care. During incontinence care, the resident rolled out of bed and sustained a small skin tear on the forehead. The incident occurred while a nurse aide was providing care alone, did not have the resident positioned in the center of the bed, and turned the resident away from herself, resulting in the resident falling face-first onto the floor. There was no evidence of in-service education provided to staff after the incident regarding safe positioning and turning techniques, and the facility did not have a complete investigation file for the incident. Another resident with dementia and severe cognitive impairment was assessed as low risk for elopement but exhibited exit-seeking behavior the day before an elopement event. The resident attempted to leave the facility, became confused, and was redirected by staff. The following day, the resident exited the facility unsupervised by following a discharging resident and family member out the front entrance, which was unlocked during the day. The receptionist, who was unfamiliar with the resident, did not recognize him as a resident and did not intervene. The resident was later found by a staff member approximately 0.7 miles from the facility, having traversed a busy highway and multiple intersections. Staff were unaware the resident was missing until notified by the staff member who found him. The facility did not have a system in place to identify residents at risk for elopement or to ensure staff, including the receptionist, could distinguish between residents and visitors. There was no photo book or other method at the reception desk or nurses' stations to identify residents with exit-seeking behaviors. Communication lapses occurred, as staff working with the resident on the day of the elopement were not informed of the resident's exit-seeking behavior the previous day. The lack of supervision and identification systems contributed to the resident's unsupervised exit and the potential for serious harm.