Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure the safety of residents at risk for elopement and those requiring assistance with transfers, resulting in multiple deficiencies. For one resident with dementia and severe cognitive impairment, the facility identified a risk for wandering but did not develop or implement a care plan or interventions to address this risk. When the resident was discovered missing, staff did not follow the facility's elopement policy, including failing to call a missing person code or notify the police and DON promptly. The resident was eventually found by police several miles away after walking along a dangerous road, but only after a significant delay in response. Another resident, identified as an elopement risk with Alzheimer's disease, was able to exit the facility through a Wanderguard-alarmed door that was not properly closed and latched. The door had a history of malfunctioning, and staff failed to ensure it was secured after use. As a result, the resident exited into the parking lot and sustained serious injuries, including head lacerations, a subdural hematoma, a subarachnoid hemorrhage, and a nondisplaced fracture, after falling. Interviews revealed ongoing issues with the door hardware, which had not been addressed by the facility owners despite repeated concerns from maintenance staff. A third resident, dependent on staff for transfers due to dementia and Parkinson's disease, was transferred by a single agency nurse aide without the required two-person assistance or use of a mechanical lift, contrary to physician orders and care plan directives. The aide did not check the assignment sheet or care card before performing the transfer and did not use a gait belt. The resident subsequently sustained a significant femur fracture, requiring transfer to a trauma center for surgical intervention. The investigation confirmed that the aide was unaware of the resident's transfer requirements and failed to follow established protocols.