Failure to Supervise Cognitively Impaired Resident with Vehicle Access
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and implement necessary interventions to prevent accidents for a resident with Alzheimer's disease and moderately impaired cognition. The resident, who had a history of forgetfulness and required assistance with activities of daily living, was able to leave the facility multiple times without staff awareness or proper sign-out procedures. On several occasions, the resident left the premises in a personal vehicle, including one incident where he traveled to another city and another where he was found lost and returned by police. Despite these incidents, the resident's care plan did not initially include interventions addressing his access to a vehicle or his ability to drive. The facility's records showed that the resident's cognitive impairment and diagnosis of Alzheimer's were known, and staff were aware that he required supervision and cues for safety. However, after the resident left the facility and drove significant distances without staff knowledge, there were no immediate updates to his care plan to address the risk associated with his access to a vehicle. Interviews with staff and family confirmed that the resident was able to leave the facility unsupervised, and staff were not consistently verifying sign-out and return procedures. The resident's responsible party and staff expressed concerns about his ability to drive safely due to his cognitive deficits. The facility's policy required assessment and care planning for residents at risk of elopement or unsafe wandering, but these measures were not effectively implemented for this resident. Staff interviews revealed gaps in communication and understanding of protocols related to resident supervision and sign-out procedures. The lack of timely interventions and supervision allowed the resident to repeatedly leave the facility and operate a vehicle, despite clear risks associated with his medical condition and cognitive status.
Removal Plan
- Resident #1 received a head-to-toe assessment.
- Resident #1 was placed on 1:1 monitoring.
- The physician was notified and lab orders were obtained with no abnormalities noted.
- The care plan was updated with updated interventions of 1:1 monitoring, documenting exit seeking behaviors, and laboratory studies were completed.
- The vehicle belonging to Resident #1 which was on the premises was removed by resident's Relative Z and moved to her premises.
- Resident #1 has not driven a vehicle.
- The employee monitoring the reception desk was suspended and returned to work.
- Staff member was provided with 1:1 education on following proper out on pass process.
- Nursing administration conducted a facility wide audit of all current residents to determine if any residents were operating personal vehicles that were on the facility's premises.
- The facility completed an audit of all residents wandering evaluations.
- No new residents found at risk for wandering/elopement.
- The center developed and implemented a process to ensure safe and proper leaves of absence for residents: the center developed and implemented a Front Door Safety & Sign-Out Procedure.
- Staff members who assist with front desk reception duties were educated on the new process of Front Door Safety & Sign-Out Procedure to include competency check off.
- The facility initiated 100% reeducation on Elopement Protocols and the supervision of residents and ANE.
- The facility initiated 100% reeducation with the Charge Nurses on the process of Front Door Safety & Sign-Out Procedure.
- The training of direct care staff was completed in person or via telephone.
- Those that were not scheduled completed reeducation prior to accepting assignment for the next scheduled work.
- Verification of 100% of direct care staff education was verified by the Director of Nursing/ designee.
- Employee roster was utilized to validate completion.