Resident Elopement Due to Inadequate Supervision and Failure to Identify Exit-Seeking Behavior
Penalty
Summary
A deficiency occurred when a resident with a history of metabolic encephalopathy, chronic kidney disease, and intermittent memory problems was able to leave the facility without staff awareness. The resident was admitted as oriented to person, place, and time, and initial elopement risk assessments did not identify him as at risk for elopement. However, the resident exited the facility by following a visitor out the front door, which was unlocked by the receptionist, who did not recognize him as a resident at the time. The resident was missing for approximately 1.5 hours before being located at a nearby apartment complex, after crossing a parking lot and service road. During the time the resident was missing, staff did not notice his absence. An LPN assumed the resident was in therapy and did not verify his location. The facility's elopement book and risk lists were not effectively used to identify or monitor the resident, and the receptionist was not aware of the resident's status. The incident was only discovered when the apartment complex staff contacted the facility, prompting the Maintenance Director to retrieve the resident. Law enforcement was also involved after being called to the apartment complex, where the resident was found confused and unable to explain how he had arrived there. The facility's policies required regular elopement risk assessments and quarterly elopement drills, but the resident's risk status was not updated until after the incident. Staff interviews revealed that while elopement drills and in-services had been conducted, there was a lack of immediate recognition and response to the resident's absence. The failure to provide adequate supervision and to ensure the area was free from accident hazards resulted in the resident's unsupervised departure and subsequent exposure to potential harm.