F0689

J

Failure to Supervise Resident with Exit-Seeking Behaviors Resulting in Elopement and Injury

Cincinnati, Ohio Survey Completed on 09-30-2025

Penalty

No penalty information released

Summary

A resident with a history of traumatic brain injury, schizoaffective disorder, severe cognitive impairment, and documented exit-seeking behaviors was admitted to the facility with recommendations for one-to-one staff support as needed. The resident's care plan included interventions for high elopement risk, such as secured unit placement, observation for changes in mental status, and one-to-one supervision when necessary. Despite these interventions, the resident continued to display delusions, disorganized thinking, mood swings, and paranoia, and had previously made statements about leaving the facility and jumping out of a window.

On the day of the incident, multiple staff members observed and reported concerning behaviors by the resident, including entering another resident's room inappropriately, attempting to take excessive food, and making explicit threats to jump out of a window. These threats were communicated to various staff, including a CNA, an activity assistant, and an LPN. However, the LPN did not assess or remain with the resident after being informed of the threats, instead allowing the resident to return to his room alone. Other staff members either dismissed the seriousness of the threats or failed to communicate them to the appropriate personnel. At the time of the incident, the LPN was reported by some staff to be sleeping at the nursing station, though the LPN denied this.

Shortly after the threats were made and reported, the resident broke a second-story window and exited the building by jumping out, resulting in an open fracture to the left ankle. The resident was found on the ground outside the unit and was subsequently transported to the hospital for treatment. The facility's investigation revealed that staff did not provide adequate supervision or timely intervention in response to the resident's exit-seeking and self-harm threats, which directly led to the elopement and injury.

Removal Plan

• The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) interviewed staff from the unit to gather statements regarding the incident.
• The DON and ADON provided education to current staff on suicidal and threatening behavior protocols and interventions, behavior management, and how to deal with challenging behaviors and the need to immediately respond to resident threats of self-harm.
• Staff were instructed that the resident should not be left alone or out of line of sight for their safety. If the nurse does not respond, then they should notify the DON/ADON/Administrator.
• The DON and the ADON reviewed the suicidal ideation (SI) risk assessment/questionnaire.
• The DON and the ADON educated staff on the abuse and neglect policies and procedures.
• The DON notified staff who were not present on the date(s) of the incident via online communication that they must report to the DON/ADON for education before their next scheduled shift.
• Ongoing training will continue for all employees who have not yet received it due to paid time off (PTO), sick leave, etc., and will also be provided to all new hires.
• The ADON completed suicide risk assessments and elopement assessments for all current residents on the male secured unit, and no other residents were identified with suicidal ideations or increased/current immediate elopement risk.
• The Maintenance Director (MD) audited all second-floor windows to ensure they were secured and in place with no further issues noted.
• Staff secured Resident #11's room to prevent re-entry and cleared glass debris from the courtyard for safety.
• The facility Administrator opened a Self-Reported Incident (SRI) and reported the incident to the Ohio Department of Health (ODH).
• The Administrator suspended Licensed Practical Nurse (LPN) #205 who was the unit nurse at the time of the incident, pending the outcome of the investigation.
• The Administrator and the DON notified the Medical Director and a member of the governing body (GB)/Owner of the incident.
• The facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting by phone with the Administrator, the DON, the Medical Director and the Facility Owner.
• The Administrator and the DON completed a root cause analysis of the incident and determined the root cause was staff did not stay with Resident #11 when the resident verbalized an intent to leave the facility by jumping out a window and LPN #205 failed to assess Resident #11 when notified by staff.
• The ADON began questioning random staff three times weekly to verify knowledge of resident safety protocols. Results are turned into the Administrator for ongoing monitoring and compliance. The ADON will continue the monitoring three times weekly for three months.
• The management team will conduct ongoing education and continue to address any issues related to suicidal and threatening behaviors.
• Staff have been and will continue to be questioned by the Administrator or designee on appropriate actions to take if a resident expresses an intent to harm themselves. This will be conducted three times per week for three months, and results will be reported to the QAPI committee.
• The facility Psych Nurse Practitioner (NP) and outside counseling service representatives met with all residents on the secured male unit to provide support.
• RCO #800 provided re-education to the current Administrator and the acting Administrator at the time of the incident on the importance of a thorough investigation and the need to review the accuracy and information provided by staff.
• The Administrator notified LPN #205 that after investigation LPN #205's employment was terminated.