Failure to Prevent Elopement and Injury Due to Inadequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to ensure resident safety and prevent accidents for two residents. One resident, who had diagnoses including dementia, bipolar disorder, and generalized anxiety disorder, was identified as being at risk for elopement and had a Wander Guard device ordered and care planned to prevent unsupervised exit. Despite these interventions, the resident was able to remove the Wander Guard multiple times and ultimately left the facility without staff knowledge. The resident was found off facility grounds at a nearby gas station without the Wander Guard, and staff interviews confirmed that the resident had a history of removing the device and that the device's placement was not changed to prevent removal. Another resident, with diagnoses including parkinsonism, hemiplegia, and hemiparesis, and who used a wheelchair for mobility, experienced an avoidable fall during transportation to a medical appointment. The resident was cognitively intact and reported that the wheelchair was not properly secured in the van, despite notifying the driver twice. The driver failed to ensure the resident was properly fastened using the required seatbelt and four anchors, as per training and facility policy. Upon arrival at the destination, the resident fell out of the wheelchair inside the van, resulting in a left femur fracture that required surgery. Staff interviews and documentation confirmed that the driver had been trained on proper safety protocols but did not follow them during this incident. Facility policies reviewed indicated that resident safety and supervision are priorities, with ongoing identification of safety risks and environmental hazards, and that employees are to be trained to prevent avoidable accidents. The policies also specified interventions for residents at risk of wandering and elopement. In both cases, the facility did not implement or maintain effective interventions to prevent the identified hazards, resulting in one resident eloping and another sustaining a serious injury during transport.