Failure to Prevent Resident Elopement Due to Ineffective Administrative Oversight
Penalty
Summary
The facility administration failed to effectively use its resources to ensure resident safety and maintain the highest practicable physical and mental well-being of residents. Specifically, the facility did not implement adequate measures to prevent a resident identified as being at risk for wandering from exiting the building unattended and entering an unsafe environment. Review of job descriptions for the Nursing Home Administrator (NHA) and Director of Nursing (DON) indicated their responsibilities included maintaining safety, staffing, and overall operations in accordance with regulations. However, on the date of the incident, a resident exited the facility without staff supervision, demonstrating that facility systems and oversight were not effective in preventing unsupervised exits for residents at risk of wandering. Interviews with staff, residents, the NHA, and the DON confirmed that established safety measures were not followed, and both equipment and staff procedures failed. Staff expressed uncertainty about their roles in monitoring exit doors and about communication protocols when a resident was missing. This lack of coordination and communication delayed the identification of the incident and assessment of other residents at risk for wandering or elopement. The NHA and DON did not fulfill their essential administrative duties to monitor departmental operations, identify systemic risks, and ensure the implementation of facility policies to maintain resident safety, resulting in immediate jeopardy to residents' health and safety.