Failure to Prevent Accidents and Elopement Due to Inadequate Supervision and Unsafe Transfer Practices
Penalty
Summary
The facility failed to ensure safe transfer practices and adequate supervision to prevent accidents and elopement for several residents. One resident with muscle weakness and morbid obesity, who was cognitively intact and required substantial assistance for transfers, was dropped during a transfer from a shower to bed. Despite the resident's care plan and facility policy requiring the use of a mechanical lift for residents of his size and condition, staff attempted the transfer manually without a mechanical lift or gait belt. Multiple staff members, including CNAs, LPNs, and maintenance personnel, were involved in lifting the resident from the floor to the bed after the incident. Interviews with staff and therapy personnel confirmed that a mechanical lift should have been used, and staff could not explain why it was not utilized during the transfer. The facility also failed to provide adequate supervision and monitoring for three residents at risk for elopement. One resident with severe cognitive impairment and a history of wandering was able to leave his unit, exit the building, and was found across the street without staff supervision. The incident was attributed to failures in communication, lack of immediate staff response, and absence of physical safeguards or secure access for residents at risk of elopement. The care plan for this resident was not updated with further interventions after the incident. Another resident, moderately impaired and at moderate risk for elopement, exited the main doors and was found in the parking lot. Staff statements indicated confusion about code orange procedures, and the facility's intercom system was not fully operational, contributing to delayed response. A third resident, cognitively intact and not assessed as at risk for elopement, was reported missing from his unit overnight. Staff failed to follow required notification procedures when the resident was not found in his room, and there was a lack of timely action to locate him. The resident was eventually found to have left the facility and returned several days later. These incidents demonstrate lapses in supervision, monitoring, and adherence to established protocols for resident safety and accident prevention.