Date: 9/23/2019
Report Number: OR0002114501
Allegation: Failed to assure resident was safe
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Description: Based on observation, interivew and record review it was determined that the facility failed to provide Resident 22 adequate care and services related to elopement. Resident 22 had a history of past elopements and Behavior Care Plans listed behaviors to monitor that included pacing and exploring the fence line and intrusive behaviors. Facility progress notes indicated an increase in Resident 22's behaviors and on or about September 22, 2019 the resident was observed to walk outside into the gated courtyard, kick down the fence, and exit the factility courtyard. Staff indicated that Resident 22 was allowed to go outside, was watched from inside of the facility every once in a while, and not monitored continuously while outside. Facility failure to monitor Resident 22 placed the resident at risk for adverse effects. Federal enforcement recommended.
Rule(s) Violated: 411-086-0060(2)(h)
411-086-0140(2)
Result: Substantiated
Findings: The facility failed to ensure the resident's safety regarding elopement.