Failure to Assess and Supervise Resident with Elopement Risk Resulting in Severe Injury
Penalty
Summary
The facility failed to ensure the safety and adequate supervision of a resident with a history of dementia, major depressive disorder, and psychosis, who exhibited exit-seeking and aggressive behaviors. Upon initial admission and subsequent readmission, the facility did not complete or properly document the required Wandering Risk and Elopement Screening Assessment. Despite multiple episodes of exit-seeking and attempts to leave the facility, the resident's care plan was not updated to reflect these behaviors, and no comprehensive elopement prevention plan was developed. On several occasions, staff observed the resident attempting to leave the facility, displaying delusional and aggressive behaviors, and expressing a desire to go home. Staff interviews revealed that the resident was known to be confused, at risk for elopement, and had previously attempted to access exits. On the day of the incident, the resident became agitated, climbed onto her bed, and began kicking a window in an attempt to escape. Although a 1:1 sitter was ordered, the assigned LVN was also responsible for 28 other residents and did not request additional staff support. The LVN did not continuously monitor the resident, and there was confusion among staff regarding who was providing direct supervision at the time of the incident. As a result of inadequate supervision and failure to intervene, the resident broke the window and sustained severe injuries, including a right tibial plateau fracture and a comminuted fracture of the fibular head and neck, requiring hospitalization and surgical intervention. Documentation and interviews further revealed that staff failed to follow up on psychiatric consult orders and did not implement immediate safety strategies as outlined in facility policies. There were also allegations of staff being pressured to falsify statements regarding the incident.