State Findings:
Based on interview, record review, review of the hospital Emergency Department (ED) record, Emergency Medical Services (EMS) record, and the facility’s policy, it was determined the facility failed to provide adequate supervision and monitoring to prevent elopement for one (1) of three (3) sampled residents (Resident #1).
On 04/02/19, a care plan meeting was held due to Resident #1 trying to take windows apart. On 04/10/19 and 04/11/19, work orders were placed due to screens being partially pushed out in room [ROOM NUMBER]; a window propped up by a picture frame; a screen out of a window in room [ROOM NUMBER]; and, a torn screen. In addition, on 04/14/19, Resident #1 lifted a window and pushed the window screen from the window in the dining room; and, on 04/14/19 at 8:22 AM, Resident #1 attempted to elope/exit from the facility through a window, where the screen had been removed. However, the facility failed to ensure increased supervision was put in place to address the resident’s tampering with the windows/screens, and attempting to exit the facility.
On 04/15/19, Resident #1 propped a window open with a picture frame, pushed the screen from the window, climbed a (6) six foot privacy fence, and eloped/exited the facility, without staff knowledge. The resident was located in a residential neighborhood two (2) blocks away (approximately 0.22 miles) by local law enforcement after they had been notified of someone looking for a halfway house in the neighborhood.
The facility’s failure to provide adequate supervision related to wandering/exit seeking behavior has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/25/19 and the facility was notified of the Immediate Jeopardy on 04/25/19.
Interview on 04/23/19 at 2:57 PM and on 04/25/19 at 11:45 AM with LPN #3 revealed Resident #1 has wandering on his/her care plan but no interventions were placed on Resident #1’s care plan the night the screens were removed in Resident #1’s room. Interview on 04/25/19 at 12:18 PM with LPN #4 revealed about a week before resident eloped, Resident #1 had been trying to take windows out in his/her room, but she had caught the resident and put them back in (windows and screens). LPN #4 stated she did not think the resident could get out of the window and he/she had said that he/she was not trying to escape. She revealed she reported the incident and also placed it on the twenty-four (24) hour report.
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If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
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