Failure to Supervise High-Risk Residents Results in Elopement and Aggression
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for residents identified as high risk for elopement and physical aggression. Two residents with severe cognitive impairment and documented elopement risk were not properly supervised, resulting in both exiting the secured, locked unit through a broken window. One of these residents was assigned to one-to-one (1:1) supervision at the time but was left unsupervised when the assigned CNA left the unit to use the restroom. The residents were able to break a window, exit the facility, and one subsequently stole an unsecured vehicle from the facility parking lot, driving it a significant distance before being apprehended. Documentation revealed repeated incidents of these residents tampering with security devices, refusing monitoring devices, and exhibiting exit-seeking behaviors, yet the facility lacked a policy for supervision or 1:1 monitoring and failed to implement effective interventions to prevent elopement. Another resident with a history of schizoaffective disorder, impulse control issues, and aggressive behaviors was also not adequately supervised despite being on 1:1 observation. This resident engaged in self-injurious behavior and physically assaulted staff on multiple occasions, including punching a nurse in the face and assaulting law enforcement. Staff interviews revealed a lack of training and clear protocols for managing aggressive or self-harming behaviors, with staff expressing uncertainty about how to intervene during such incidents. The care plan for this resident included instructions for 1:1 supervision and specific monitoring, but staff reported only general abuse and neglect training and no specific guidance for handling violent or self-harming behaviors. The facility did not have policies in place for resident supervision or 1:1 observation, and staff were not provided with clear expectations or training prior to the incidents. The lack of effective supervision, absence of policies, and failure to address known risks led to multiple serious incidents, including elopement, self-injury, and physical assaults. The cumulative effect of these failures resulted in a finding of Immediate Jeopardy, with the situation ongoing at the time of the survey exit.