Failure to Prevent Elopement, Falls, and Transport Injuries Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that residents received adequate supervision to prevent accidents, resulting in multiple incidents involving elopement, falls, and injuries. Three residents with cognitive impairment eloped from the facility, with two of these incidents reaching the level of immediate jeopardy. In one case, a resident with severe cognitive impairment and a history of elopement repeatedly escaped the facility by breaking through or climbing over fences, sometimes requiring staff intervention to prevent the resident from entering traffic. Documentation showed that staff were aware of the resident's behaviors, but interventions were limited to verbal redirection and monitoring, and not all incidents were reported or investigated as required. Another resident with vascular dementia and agitation also eloped on multiple occasions by climbing over fences, resulting in a skin tear during one incident. Despite these events, there was no evidence that the resident's elopements were investigated or reported to the state survey agency. Additionally, this resident experienced several falls, including incidents where the resident hit his head or was found on the floor, but the care plan was not updated to reflect new interventions after these falls. Staff interviews confirmed that interventions were not consistently added to the care plan following such incidents. A separate incident involved a resident who was not properly secured in a facility van during transport, resulting in the resident tipping backward in his wheelchair and sustaining a head abrasion. The staff member responsible for transport admitted to not securing the wheelchair correctly and stated that initial training was verbal and lacked demonstration. Documentation of training was incomplete, and the facility could not provide evidence that the staff member had been properly trained prior to the incident. Other residents were also found in unsafe positions, such as lying on the floor or between the bed and wall, without staff present or timely intervention.