Failure to Prevent Resident Elopement Due to Inadequate Supervision and Policy Implementation
Penalty
Summary
The facility failed to implement its policy and procedure regarding wandering and elopement, resulting in a resident with a history of confusion and agitation leaving the premises unsupervised. The resident, who had been admitted with diagnoses including type 2 diabetes mellitus and asthma, was observed wandering and entering other resident rooms earlier in the evening. Despite these behaviors, a Certified Nursing Assistant (CNA) observed the resident leaving the facility late at night but did not intervene or attempt to identify the individual, as the resident was wearing street clothes and appeared to be walking normally. The CNA later acknowledged that he did not recognize the person leaving and did not stop to verify their identity or purpose for leaving, only realizing after being informed that a resident was missing that the individual was likely the resident in question. The facility's policy required staff to attempt to prevent residents from leaving, seek assistance from other staff, and notify nursing leadership if a resident was observed leaving the premises. These steps were not followed in this instance. The resident was subsequently found by local law enforcement and taken to a hospital for evaluation. Interviews with facility staff, including the Director of Nursing, confirmed that the CNA should have stopped and identified the individual leaving the building, especially given the time of night and the resident's lack of reflective clothing. The failure to follow established procedures resulted in the resident leaving the facility unsupervised.