Failure to Prevent Elopement and Inadequate Fall Risk Management
Penalty
Summary
The facility failed to immediately respond to an elopement incident involving a resident with mild cognitive impairment, chronic kidney disease, and a history of wandering. The resident, identified as an elopement risk and equipped with an exit alarm bracelet, was able to leave the facility without appropriate clothing for extremely cold weather. When the exit alarm sounded, staff initially searched the wrong area and did not immediately pursue the resident outside, despite visual confirmation of her location. The resident was eventually found by a staff member approximately 15 minutes later, outside and exposed to cold temperatures, with red face and very cold hands. Additionally, the facility did not conduct comprehensive investigations or root cause analyses for multiple falls experienced by another resident with cognitive impairment and impaired mobility. The fall investigations often lacked thorough assessments of contributing factors such as toileting needs, call light placement, and footwear. Interventions were inconsistently implemented or documented, and care plans were not promptly or adequately revised to address the identified risks and causal factors for repeated falls. Staff interviews revealed gaps in training and understanding of elopement prevention and response protocols. Documentation and care planning for fall prevention were incomplete, with delays in updating interventions and a lack of comprehensive analysis following each incident. The facility's policies required individualized interventions and ongoing evaluation, but these were not consistently followed, resulting in repeated deficiencies in accident prevention and resident supervision.