Elopement and Injury Due to Inadequate Supervision and Lapse in Security Protocols
Penalty
Summary
A deficiency occurred when a resident, identified as an elopement risk with diagnoses including Alzheimer's Disease, cognitive communication deficit, amnesia, and dementia with moderate agitation, was able to exit a secured unit and leave the facility undetected by staff. The resident was later found sitting on the curb in front of the facility and was subsequently transferred to the hospital emergency department, where a left elbow fracture was diagnosed. The resident's care plan indicated the need for increased supervision and distraction with alternative activities to maintain safety. Facility policies required identification of residents at risk for unsafe wandering and the implementation of supervision based on individual needs and environmental hazards. The policies also specified that staff must monitor visitors and ensure that residents do not leave the secured unit or facility without appropriate supervision. On the day of the incident, a visitor was touring the secured unit and was allowed access to the elevator by a staff member. The resident followed the visitor onto the elevator and exited the building, apparently unnoticed by staff at the reception desk, who was responsible for monitoring entry and exit. Interviews revealed that staff members on the unit denied entering the elevator code for the visitor, and the receptionist did not realize the resident had exited. The Director of Nursing confirmed that staff were expected to remain at the elevator until it closed to ensure no residents left the secured unit. The failure to provide adequate supervision and to follow established protocols for monitoring residents and visitors resulted in the resident's elopement and subsequent injury.