Failure to Provide Adequate Supervision Resulting in Resident Burn and Elopement
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for two residents, resulting in one resident sustaining a burn and another resident eloping from the facility. For the first incident, a resident with diagnoses including diabetes, depressive disorder, and hypertension was admitted to the facility and had physician's orders for restorative dining. During an activity in the dining area, coffee provided by the Activities department was served without checking its temperature. The resident spilled the coffee in her lap, resulting in a red, blistered burn. The incident was reported by a CNA, and it was confirmed that the coffee temperature was not measured prior to serving. In the second incident, a resident with anemia, renal insufficiency, and vascular dementia, who had a known history of wandering and was assessed as an elopement risk, was not provided with adequate supervision or individualized interventions to prevent elopement. The resident's baseline care plan did not include specific interventions for supervision or elopement prevention. Despite being fitted with a wander guard, the resident was able to remove it and eloped to another unit within the facility. On a subsequent occasion, the resident exited the facility through the front doors, triggered the wander guard alarm, and was found outside by another resident's family member. Staff interviews, facility policy reviews, and documentation confirmed that the facility did not follow its own policies regarding accident prevention and elopement. The Director of Nursing and the Nursing Home Administrator acknowledged the lack of adequate supervision and failure to implement resident-centered interventions for the identified elopement risk, as well as the failure to ensure a safe environment in the dining area, which resulted in the resident's burn.