Failure to Verify Resident Presence After Discovery of Unsecured Window on Secured Unit
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention on a secured memory care unit when staff did not verify that all residents were present after discovering an unsecured window. A resident with paranoid schizophrenia and unspecified psychosis, identified through multiple elopement risk evaluations as an elopement risk due to schizophrenia and wandering behaviors, had care plan interventions that included ensuring safety on a secured unit and monitoring exit-seeking behaviors such as pushing on exit doors. On the morning of the incident, a restorative nurse aide notified an LPN that the plywood covering a previously broken window on the secured unit was missing. The LPN, who had last seen the resident near the nurses’ station at approximately 6:00 AM, assumed the plywood had been removed by another resident known for breaking windows and exit-seeking, and did not initiate a head count or otherwise confirm that all residents on the unit were present. Later that morning during breakfast, staff noticed the resident was not present in the dining room and began searching for the resident on the unit and then in the surrounding area after the resident could not be located. The administrator confirmed that when staff discovered the missing plywood and unsecured window between 7:00 AM and 8:00 AM, they notified the administrator and confirmed only that the resident assigned to that room was present, but did not complete a full resident count on the secured unit. The facility’s elopement policy defined elopement as a resident exiting the facility or entering an unsafe area without staff knowledge and required care plan interventions based on elopement risk evaluations. An additional facility document on elopement risk directed staff to ensure all doors and windows in the memory care unit were locked and secured and to complete an immediate head count for the entire facility if any potential elopement risk, such as an open door or window, was identified. Staff’s failure to follow these procedures resulted in delayed identification of the resident’s elopement and delayed implementation of the facility’s elopement response procedures.
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