Failure to Prevent Elopement and Incomplete Investigation of Injury
Penalty
Summary
A cognitively impaired resident with a history of falls and wandering was not adequately supervised, resulting in the resident eloping from the facility. The resident, who required staff supervision for ambulation and used a walker, was last seen in the lobby by staff, with her walker left behind. Staff discovered the resident missing and found her outside in the facility van during high temperatures, without knowledge of how she exited the building. The door alarm did not activate, and the care plan lacked specific interventions for elopement risk, despite documented wandering behavior and a history of elopement attempts. Additionally, the facility failed to conduct a complete investigation when another resident sustained two skin tears of unknown origin. The resident, who was dependent on staff for transfers and had moderate cognitive impairment, reported that her leg was injured during a transfer. The incident report did not include a dated witness statement, and the facility was unable to provide documentation from the staff member involved in the transfer. The facility's policy required thorough investigation and documentation of all injuries of unknown origin, but this was not completed as required. Both deficiencies were identified through observation, record review, and staff interviews. The lack of adequate supervision and incomplete investigation placed the residents at risk, with one incident resulting in immediate jeopardy due to the resident's unsupervised exit and exposure to unsafe conditions.