Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident identified as being at risk for wandering and elopement. The resident had a history of exit-seeking behaviors, multiple prior elopement attempts, and was assessed as an elopement risk due to cognitive impairment, poor decision-making skills, and independent ambulation. The resident's care plan included interventions such as frequent monitoring, 1:1 supervision, room relocation away from exits, and the use of an electronic monitoring device. Despite these interventions, the resident was able to exit the facility through an alarmed door and was found by staff and law enforcement outside the facility after being missing for nearly an hour. On the night of the incident, staffing was compromised due to a CNA not showing up for the shift, resulting in only three CNAs present instead of the scheduled four. The remaining CNAs implemented an hourly rotation for 1:1 supervision of the resident. However, lapses in supervision occurred during shift changes and when CNAs attended to other residents, leaving the resident unsupervised. Staff interviews confirmed that the CNA assigned to supervise the resident was not present at the time of elopement, and the LPN on duty was unaware of the resident's whereabouts until the door alarm sounded. The resident, who had multiple medical diagnoses including hypertension, diabetes, hip fracture, seizure disorder, and dependence on dialysis, was found outside the facility and returned safely. Documentation and interviews revealed that the facility's elopement policy did not specifically address 1:1 supervision, and staff decisions regarding supervision rotations were made without notifying facility leadership. The deficiency was directly related to inadequate supervision and failure to maintain consistent monitoring as outlined in the resident's care plan.