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 with severe cognitive impairment and multiple diagnoses, including dementia, schizophrenia, Alzheimer's disease, psychosis, muscle weakness, malnutrition, and lack of coordination. The resident, who was independently ambulatory and admitted to a secured unit due to a history of wandering and elopement attempts, was able to leave the facility undetected. On the day of the incident, the resident approached a CNA, who was subsequently distracted by other duties. An alarm sounded from the back door, which the CNA turned off without verifying the cause or notifying a nurse, as required by facility protocol. The resident's absence was not discovered until after a shift change, at which point staff initiated a search and notified the appropriate personnel. The resident was later found by police several miles away from the facility and returned safely. Interviews and record reviews confirmed that the CNA did not follow the elopement protocol, specifically by disabling the alarm and failing to alert nursing staff. The facility's elopement policy required monitoring of residents at risk for elopement and immediate action if an alarm was triggered, but these procedures were not followed, resulting in the resident's unsupervised exit from the secured unit.
Removal Plan
- Resident was placed on 15-minute visual checks by nurse
- Wander guard
- Code changed to the Secure Unit Doors
- Added a camera with motion detection on the back door
- Added a fence to the back of the facility for an extra layer of security
- Staff were trained in elopement/supervision procedures
- The care plan was updated to include a wander guard and medications were reviewed