Failure to Implement Fall and Elopement Prevention Measures
Penalty
Summary
The facility failed to ensure that accident prevention interventions were in place for two residents, resulting in deficiencies related to fall prevention and elopement. For one resident with dementia, muscle weakness, and moderately impaired cognition, the care plan included specific fall prevention interventions such as keeping a urinal at bedside, placing a bedside toilet in the room, and posting a 'please call don't fall' sign. However, during observation, none of these interventions were present in the resident's room, and the DON confirmed that the fall prevention measures were not in place at the time of the survey. Another resident with severe cognitive impairment and a history of schizophrenia eloped from the facility. The resident was found missing during staff rounds, and was later located and returned by a staff nurse who saw him walking outside. The facility's investigation revealed that the resident exited through a door that was unlocked while the fire panel was alarming. Staff interviews indicated a lack of awareness regarding the unlocking of exit doors during fire panel alarms, and there was inconsistent documentation and statements about the timing and awareness of the elopement. The medical record contained minimal documentation about the incident, and a statement from the nurse responsible for the resident was not obtained. The facility's policies required documentation and investigation of missing residents and the implementation of interventions to prevent accidents. However, the failure to implement and maintain required safety interventions for fall prevention, as well as inadequate supervision and documentation related to the elopement, led to non-compliance with accident prevention standards. These deficiencies were identified through observations, record reviews, and staff interviews.