Failure to Supervise Resident with Exit-Seeking Behaviors Resulting in Elopement
Penalty
Summary
A facility failed to provide adequate supervision to a resident with dementia and a known history of exit-seeking behaviors, resulting in the resident eloping from the secured memory care unit through a window in his room. The resident had been displaying persistent exit-seeking actions since admission, including packing belongings, attempting to open various doors, and expressing a strong desire to leave. On the day of the incident, the resident was observed to be angry, repeatedly trying to leave, and stating he needed to get out. Despite being identified as an elopement risk and assigned a security bracelet, the resident was able to manipulate and break the window hardware in his room, lay the window flat, and exit the building. Staff last observed the resident heading to his room after dinner, and he was later found by the ADON walking alone near a store approximately 100 yards from the facility. The nurse assigned to the unit was not present at the time, and the incident was not discovered until the resident was returned to the facility. The resident's clinical record documented multiple instances of exit-seeking and agitation, including attempts to leave and statements about not wanting to stay. The facility's policy required staff to know the location of residents under their care, but this was not followed, resulting in the resident's unsupervised exit from the secured unit.
Removal Plan
- audits of elopement evaluations and care plans
- inservicing staff on elopement procedures
- ongoing monitoring