Failure to Prevent Elopement and Accidents Due to Inadequate Supervision and Device Use
Penalty
Summary
The facility failed to ensure adequate supervision and the use of assistance devices to prevent elopements and accidents for two residents reviewed for elopement and falls. One resident with a history of cerebrovascular disease, moyamoya disease, and vascular dementia was found outside the facility in the early morning hours, having fallen and sustained an abrasion. The incident was not thoroughly investigated to determine the root cause of the fall or how the resident eloped from the building. Documentation was unclear regarding the functionality of the door alarms at the time, and there was no evidence that an elopement care plan was initiated following the event. Additionally, the resident's care plan was not updated to address wandering or elopement risks, despite subsequent documentation of wandering behaviors and agitation. A second elopement occurred when the same resident was discovered missing from the facility in the middle of the night and was later found by police over a mile away, sitting at a street intersection. There was no investigation into this elopement, no assessment of the resident upon return, and no revision of the care plan to increase supervision or address the incident. Staff interviews revealed confusion about the resident's risk status, the use and location of elopement binders, and the procedures for monitoring residents at risk for elopement. The facility's documentation did not reflect consistent or timely assessment, monitoring, or communication regarding the resident's behaviors and risks. Additionally, another resident experienced a fall from bed due to the bed wheels not being locked, despite a care plan intervention requiring the wheels to be locked during transfers. Observations confirmed that this intervention was not in place at the time of the fall. The facility's failure to supervise residents adequately, ensure the functionality of safety devices such as door alarms, and conduct thorough investigations into accidents and elopements resulted in a finding of immediate jeopardy. The lack of timely and comprehensive documentation, assessment, and care plan updates contributed to the ongoing deficient practice.