Failure to Supervise High-Risk Resident Resulting in Elopement and Immediate Jeopardy
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) confirmed their responsibilities to manage the facility and nursing services in accordance with federal, state, and local regulations, and to ensure 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, as proper supervision was not provided for residents at high risk for elopement. This failure led to a resident elopement and demonstrated noncompliance with professional standards of practice and facility policies.