Failure to Supervise During Fire Drill and Inadequate Medication Security
Penalty
Summary
Facility staff failed to ensure the safety and supervision of residents in a secured unit during a fire alarm test, resulting in multiple incidents of elopement and inadequate monitoring. During the fire drill, staff did not monitor the doors on the Tiger Medical Unit, which allowed a resident with significant behavioral and psychiatric diagnoses to exit the facility undetected. Surveillance footage confirmed that the resident left the building and was not noticed missing until several hours later, despite missing dinner, smoke breaks, and scheduled medications. Hourly face checks were not completed as required, and documentation was inaccurate, with checks recorded after the resident had already eloped. Additionally, two other residents were able to leave the facility through an exit door and fence during the same fire drill, as no staff were assigned to monitor these points of egress. Staff interviews revealed a lack of clear assignments and communication regarding door monitoring during fire drills, and head counts conducted after the drill were incomplete and not systematically performed. The facility's fire drill policy did not address specific staffing assignments or door monitoring procedures for secured units during drills or emergencies. The facility also failed to properly store and secure medications for several residents. Observations found unattended medications in resident rooms and on medication carts, with residents who wander frequently present in these areas. Staff interviews confirmed that medications were sometimes left out and not always administered under direct supervision, contrary to facility policy. These lapses in medication security and supervision created opportunities for residents to access medications unsafely.