Failure to Supervise Wandering Resident and Maintain Safe Environment
Penalty
Summary
A deficiency occurred when a resident with a known history of dementia, severe cognitive impairment, muscle weakness, legal blindness, and bone density disorder was not adequately supervised despite being identified as at risk for wandering and/or elopement. The resident's care plan included interventions such as increased staff supervision, quarterly elopement assessments, and the use of exit alarms. However, on the night in question, the resident was last seen by staff at 2:00 AM and was found outside the building at 4:00 AM, having sustained abrasions, bruises, and a hematoma after a fall. The exit door alarm, which was supposed to alert staff if the door was opened, did not sound, and staff were unable to determine how long the resident had been outside. Interviews with staff revealed that the resident was known to ambulate independently and wander throughout the unit, especially during the day, and was generally redirectable. On the night of the incident, the nurse's aide had last assisted the resident to the bathroom at 2:00 AM and then returned to the nurse's station, where she could see down the hallway. The aide did not hear any alarm from the exit door and only discovered the resident outside after hearing yelling at 4:00 AM. The exit door, which should have been secured with an alarm, was found to be nonfunctional at the time of the incident, although it was reported to be working when tested later that day. The facility did not have a specific policy for residents with wandering behaviors, and the only relevant policy directed staff to report missing residents and ensure adequate safeguards for resident safety. Environmental observations identified additional hazards in the courtyard area accessible from the unit, including uneven pavement, unsecured stones with sharp edges, loose rocks creating tripping hazards, a steep drop-off, and an easily opened gate leading to a pathway toward a main road. The courtyard was intended to be accessible only under staff supervision, but the physical environment was not free from accident hazards, and the exit door alarm system failed to function as required. The facility was unable to explain why the alarm did not sound or why environmental hazards were not addressed, resulting in a finding of immediate jeopardy.