Failure to Prevent Resident Elopement Resulting in Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility, resulting in the elopement of two residents. Review of job descriptions confirmed that the NHA was responsible for establishing and maintaining efficient and effective systems to safely meet residents' needs in compliance with regulations, while the DON was responsible for the organization and oversight of all nursing operations and supervision of resident care. Despite these responsibilities, the facility did not prevent the elopement of two residents, which created an immediate jeopardy situation. This failure was identified through review of job descriptions, clinical records, and staff interviews, and it was determined that the NHA and DON did not fulfill their essential job duties to ensure adherence to federal and state guidelines and regulations.