Failure to Prevent Elopement and Address Accident Hazards
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident with severe cognitive impairment, Alzheimer's disease, and a history of exit-seeking behaviors was able to leave the facility without staff knowledge. The resident was last seen in the lobby in the early evening and was later found by a bystander walking unsteadily on a nearby road, having experienced falls and an incontinent episode. The facility was unaware of the resident's whereabouts for several hours until notified by an external party. Prior to the incident, the resident's care plan did not include interventions for elopement risk, despite previous assessments indicating a history of elopement or exit-seeking behaviors. Staff interviews revealed inconsistent awareness of the resident's risk, and the front door was not secured at the time, allowing the resident to exit undetected. Additionally, the facility was found to have an unsecured, empty oxygen tank on the floor in another resident's room, presenting a potential accident hazard. This situation exposed residents to possible harm, injury, or death due to inadequate monitoring and environmental safety measures. The facility's policies required identification and mitigation of hazards, as well as routine checks and documentation, but these were not effectively implemented in these cases. Interviews with staff indicated that while some were aware of general elopement protocols, there was a lack of specific interventions and communication regarding residents at risk for elopement. Documentation and care planning did not reflect the resident's exit-seeking behaviors, and staff did not consistently monitor or report such behaviors. The failure to secure the environment and provide adequate supervision directly contributed to the resident's elopement and the presence of accident hazards in the facility.