Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The facility failed to ensure effective management and supervision for residents identified as high risk for elopement, resulting in an actual elopement event that created an immediate jeopardy situation. Review of job descriptions for the Nursing Home Administrator (NHA) and Director of Nursing (DON) showed that both roles are responsible for ensuring compliance with federal, state, and local regulations, as well as maintaining the highest degree of quality care. However, based on facility and clinical records, as well as staff interviews, it was determined that the NHA and DON did not fulfill these responsibilities, specifically by not providing the required supervision for high-risk residents. This lapse led to a resident elopement, indicating a failure to provide care and treatment in accordance with professional standards of practice and facility policies.