Failure to Provide Competent Staff for Behavioral Health Needs Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that there were sufficient staff members with the appropriate competencies and skills to meet the behavioral health needs of residents, specifically those with mental and psychosocial disorders. On the date in question, all staff assigned to the dementia unit were new agency staff who lacked prior knowledge of the residents and the unit. Review of training records for these staff members revealed no evidence of facility training or competency in dementia care or in caring for residents with behavioral health needs. During the shift, three nurse aides were observed sitting in the common area with limited interaction with residents, and one was using a cell phone. A resident, who was alert and oriented only to self and identified as being at risk for elopement due to impaired safety awareness, was able to leave the unit through a staff-access-only exit door. The resident was missing for approximately 30 minutes before being returned to the facility by local police, having been found at a neighbor's house. The care plan for this resident included interventions such as distraction, structured activities, and reorientation strategies, but these were not implemented by the staff on duty. The incident was attributed to the lack of staff training and familiarity with the residents' needs.