Failure to Provide Adequate Supervision Resulting in Resident Elopement and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of falls, partial weight bearing status, and an amputation was able to exit the facility unsupervised during inclement weather. The resident had previously demonstrated attempts to leave the building, including an incident where the resident attempted to exit the facility and refused to return to the unit, but the care plan was not updated to address this behavior. There was no evidence that an elopement evaluation was completed after the initial incident, nor was the care plan revised to include interventions for wandering or elopement risk prior to the subsequent event. On the day of the incident, the resident exited the building in the early morning hours without staff knowledge, during a snowstorm with freezing temperatures. The resident fell outside after dropping a cane and was unable to get up, remaining outside for approximately an hour. The resident was found by staff after calling for help, presenting with significant frostbite and blisters on both hands, and was subsequently hospitalized for further evaluation and treatment. Staff interviews revealed that the resident was able to disengage the alarm system using the emergency exit button, and that staff were not aware of the resident's absence until the resident was discovered outside. The facility's policy required adequate supervision and individualized care planning for residents at risk of wandering or elopement. However, the resident's care plan did not reflect the risk behaviors observed, and staff, including the Administrator and DON, were unaware of the prior incident and did not implement additional supervision or interventions. The lack of timely assessment and care plan updates contributed to the resident's ability to leave the facility undetected, resulting in an unwitnessed fall and frostbite injuries.