Failure to Prevent Resident Elopement and Access to Hazardous Items
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who had a history of cerebral infarction, aphasia, hemiplegia, and recent cranioplasty surgery, was able to elope from the facility in his manual wheelchair while awaiting transport to the hospital for severe hernia pain. Despite being identified as a wanderer with impaired cognition and requiring supervision, the resident was left unsupervised long enough to leave the building and travel half a mile to the hospital, where he was found by hospital staff. Interviews with staff and family confirmed that the resident was not wearing appropriate clothing or assistive devices and that staff were unaware of his absence until after he had left the premises. Another resident, with diagnoses including Parkinson's disease, unspecified dementia, and major depressive disorder, was able to access a hand saw from an unlocked maintenance office. This resident, who had a care plan noting potential for physical aggression and impaired cognition, was observed by staff using the saw on another resident's walker and admitted to threatening to cut off a fellow resident's foot. Staff interviews and direct observation confirmed that the maintenance office door was not consistently locked, allowing the resident to obtain the saw without restriction. The maintenance staff acknowledged the possibility of leaving the door unlocked due to being busy and in a hurry. Both incidents were confirmed through interviews, record reviews, and direct observation, demonstrating lapses in supervision and environmental safety. The facility's failure to prevent elopement and restrict access to hazardous items resulted in situations where residents were placed at risk of harm. The events were recognized as deficiencies by surveyors, with immediate jeopardy identified due to the severity of the lapses in care and safety.