Failure to Prevent Resident Fall and Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident, who was dependent for bed mobility and required a two-person assist, fell from their bed during routine care. The incident happened while two CNAs were providing in-bed care after the resident had a bowel movement. One CNA stepped away from the bedside to retrieve gloves, leaving the resident positioned on their side facing the door. During this moment, the resident rolled off the bed and was guided to the floor by staff. The resident, who had cognitive impairment, end-stage renal disease, and an above-knee amputation, reported pain in the head and shoulder and was sent to the hospital for evaluation due to being on blood thinners. The root cause was identified as a failure to maintain safe bed mobility during care, specifically not ensuring the resident was safely positioned before a staff member left the bedside. Another deficiency was identified when a resident with moderate cognitive impairment and a history of exit-seeking behavior eloped from the facility without staff knowledge. The resident was able to leave the premises with a visitor, who pushed the resident in a wheelchair out the front door. Although the resident's wander guard security alert activated the door alarm, staff did not respond in a timely manner. Witness statements revealed that staff assumed the resident was with a family member and turned off the alarm without verifying the resident's whereabouts. The resident was later found outside the facility at a nearby apartment complex by police and emergency services, unharmed. In both cases, the deficiencies were directly related to lapses in supervision and failure to follow established safety protocols. In the first incident, staff did not maintain appropriate supervision and positioning during care for a dependent resident. In the second incident, staff failed to respond appropriately to a wander guard alarm and did not follow the facility's elopement policy, resulting in a resident leaving the facility unsupervised.