Failure to Prevent Abuse, Neglect, and Elopement in Secured Unit
Penalty
Summary
The facility failed to prevent abuse and neglect for multiple residents, resulting in several serious incidents. Two residents, both identified as elopement risks with documented cognitive impairments and behavioral issues, were able to escape from a secured and locked unit. One of these residents was under one-to-one supervision at the time. The facility lacked a policy for resident supervision or one-to-one supervision, and staff were not provided with clear expectations or training prior to the elopements. Documentation revealed repeated incidents of exit-seeking behavior, tampering with alarms, and attempts to bypass security measures, yet interventions were insufficient to prevent the eventual elopement. The escape involved breaking a window, and one resident was later found walking on an interstate, while the other was located at a store miles away from the facility. The police were involved, and the events created a potential for serious injury or death. Another incident involved a resident who was immobile and left in her room with the body of her deceased roommate for nearly three hours. Despite her requests to be moved and her visible distress, staff did not accommodate her or check on her well-being during this period. The resident experienced significant psychosocial harm, including ongoing anxiety, sleep disturbances, and the need for therapy. Staff interviews confirmed that the facility's protocol should have been to move the surviving roommate before postmortem care, but this was not followed. The facility's own policy defined involuntary seclusion as a form of abuse, which was applicable in this situation. A further deficiency was identified in the care of a resident with a history of self-harm, aggression, and complex psychiatric diagnoses. This resident, also on one-to-one supervision, suffered injuries from self-harm and was involved in multiple aggressive incidents toward staff and other residents. Staff assigned to supervise this resident reported inadequate training, lack of communication tools, and feeling unsafe. Documentation of required diversional activities was inconsistent, and there was no clear policy or guidance for staff on how to conduct one-to-one supervision. The cumulative effect of these failures placed all residents at risk for abuse and neglect, resulting in a finding of Immediate Jeopardy at a widespread scope and severity.