Failure to Prevent Falls and Elopements Due to Inadequate Supervision and Investigation
Penalty
Summary
The facility failed to ensure that multiple residents received adequate supervision and that the environment was free from accident hazards, resulting in repeated falls and elopements. Six out of seven residents reviewed experienced incidents where the facility did not thoroughly investigate falls, failed to determine root causes, and did not consistently implement or revise interventions to prevent recurrence. For example, one resident with Alzheimer's disease and severe cognitive impairment experienced 15 falls over several months, including multiple falls that resulted in serious injuries such as a subdural hematoma, subarachnoid hemorrhage, T12 fracture, and hospitalizations. The facility's investigations into these falls were incomplete, lacking details such as the last time the resident was toileted, whether interventions were in place, and the root causes of the incidents. Care plans were not always updated with new interventions following falls, and staff statements were inconsistently obtained. Other residents assessed as high risk for elopement were able to leave the facility unsupervised. One resident, despite repeated expressions of intent to leave and previous attempts, was able to exit the facility and was found down the road by a family member of another resident, with staff unaware of the elopement. Another resident left the building unattended, resulting in sunburn and blisters, and later traveled nine miles in a wheelchair, nearly reaching a major highway. The facility did not have effective systems in place to monitor these residents or prevent their unsupervised departures. Additional examples of noncompliance included unwitnessed falls that were not thoroughly investigated, lack of root cause analysis, and failure to implement or document appropriate interventions after incidents. In some cases, interventions were not put in place after falls, or when residents refused certain interventions, no alternatives were provided. The facility's own policy required individualized care plans and root cause analysis for falls, but these procedures were not consistently followed, contributing to ongoing risks for residents.