Failure to Assess and Supervise Resident Use of Personal Vehicle Resulting in Elopement
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with moderate cognitive impairment and a history of alcohol abuse. The resident, who had diagnoses including cognitive communication deficit and symptoms following cerebral infarction, was allowed to store a personal vehicle on facility premises. There was no documentation of a risk assessment regarding the resident's ability to safely operate or store a vehicle, nor was there a policy or procedure in place to address such situations. The resident's care plan included interventions for alcohol abuse and potential elopement, but did not address the presence or use of a personal vehicle. The incident occurred when the resident requested access to the keys for the vehicle, which were stored in the business office. Staff accompanied the resident to the vehicle, where the resident stated he would only retrieve paperwork and start the car. Despite assurances, the resident proceeded to drive away from the facility, resulting in elopement. There was no evidence of prior documentation regarding the vehicle or any safety measures beyond key storage. Interviews with the Nursing Home Administrator confirmed the absence of relevant policies, procedures, or risk assessments for residents with personal vehicles on site.