Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents, resulting in elopement incidents involving two residents. According to the facility's Wandering and Elopements policy, residents at risk for unsafe wandering should be identified and protected from harm. One resident, with a history of diabetes mellitus, post-traumatic stress disorder, and hypotension, was assessed as moderately cognitively impaired but not at risk for elopement. Despite this, the resident was able to access the elevator and reach the lobby and front door without staff knowledge, and on another occasion attempted to exit the facility. Another resident, also moderately cognitively impaired and diagnosed with hypertension, cancer, and hyperlipidemia, was identified as at risk for elopement. Physician orders required a security bracelet to be attached to the resident's wheelchair at all times, with checks every shift. However, the resident was found on a different floor without the required alarm device on the wheelchair, contrary to the care plan and physician orders. The Nursing Home Administrator confirmed that the facility did not provide proper supervision for these residents as required.