Failure to Prevent Elopement and Ensure Safe Transfers Due to Inadequate Supervision and Noncompliance with Care Plans
Penalty
Summary
The facility failed to ensure resident safety by not providing adequate supervision and not following established care plans, resulting in two significant incidents. In the first incident, a resident with severe cognitive impairment, dementia, and a high risk for falls exited the building unsupervised through an alarmed door. The social worker, upon hearing the alarm, reset it and looked down the hallway but did not check the outside area. The resident remained outside for approximately five minutes before being brought back inside after another resident notified the social worker. The resident's care plan was updated after the incident to reflect elopement risk, but the pocket care plan did not list specific interventions to prevent elopement. Additionally, not all staff received education regarding elopement procedures following the incident, and the facility's policy did not specify that staff should check outside when a door alarm sounds. In the second incident, two certified nursing assistants (CNAs) did not follow the care plan for a resident with multiple medical conditions, including a history of falls, chronic pain, and Parkinson's disease. The care plan required that the resident be transferred with the assistance of two staff members, a gait belt, and a walker, or with one to two staff using a sit-to-stand lift. Observations revealed that one CNA assisted the resident alone using a stand and pivot transfer without a gait belt, and another CNA used a sit-to-stand lift without securing the resident's lower legs and without a second staff member. The CNAs determined the level of assistance based on their judgment rather than following the care plan, and the pocket care plan did not provide clear instructions for staff. The facility's policies required annual in-services on correct lifting and transferring procedures, including the use of gait belts and mechanical lifts. However, documentation showed that not all staff, including contracted and dietary staff, had received updated training or education on these procedures after the incidents. There was also no plan in place for monitoring or auditing compliance with elopement prevention or transfer procedures.