Failure to Supervise Cognitively Impaired Resident Resulting in Elopement and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and an environment free from accident hazards, resulting in an elopement and injuries for one resident. The resident was admitted with diagnoses including unsteadiness on feet, abnormalities of gait and mobility, and a cognitive communication deficit. An MDS assessment showed a BIMS score of 8, indicating moderate cognitive impairment. Despite these conditions and an existing care plan for risk of falls and injuries related to multiple medical issues, the care plan prior to the incident did not include interventions for monitoring wandering, use of a Wanderguard, or a personalized safety monitoring plan. There was no elopement assessment or elopement care plan in the clinical record before the resident left the facility. On the morning of the incident, the RN in charge reported that the resident was already missing when his shift began and acknowledged he should have conducted rounds with the outgoing nurse during shift report to ensure all residents were accounted for. The resident was later brought to a hospital emergency department by a bystander after reporting a misstep and unwitnessed fall, with documented head injury and an abrasion to the left hand. A complaint filed with the Department indicated the resident left the facility without informing anyone, stating he felt he was going to be killed, and that he had memory loss and impaired cognition per chart. Observations at the facility showed there was no CCTV at entrance/exit doors and three residents were on the porch without staff supervision. The receptionist confirmed there was no receptionist coverage during nighttime hours. These conditions occurred despite facility policies stating that staff must promptly report missing residents and that resident supervision and individualized, resident-centered safety interventions are core components of the facility’s safety system.
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