Failure to Prevent Resident Elopement and Ensure Staff Training
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to ensure adequate interventions and supervision were provided to prevent the elopement of two residents. One resident was able to self-remove a roam alert bracelet and exit the facility, resulting in an Immediate Jeopardy situation. The facility's action plan required that all nurses receive education on elopement prevention before their next shift and that all staff be educated by a specified date. However, documentation showed that this education was not completed as required. A second resident, who had a physician's order for one-to-one supervision due to exit-seeking behavior, also eloped after being left unsupervised by the staff assigned to provide this supervision. There was no documented evidence that the nurse aide assigned to supervise the resident or the LPN overseeing the aide had received the necessary elopement training prior to their shifts, as required by the facility's Immediate Jeopardy action plan. Additionally, 29 residents on one unit were identified as being at risk for elopement, but the required staff education was not completed for that unit. The NHA and DON failed to fulfill their responsibilities to ensure compliance with federal and state regulations, contributing to these Immediate Jeopardy situations.