Resident Elopement Due to Inadequate Supervision and Environmental Safeguards
Penalty
Summary
A resident with a diagnosis of schizoaffective disorder and severely impaired cognition was assessed as being at risk for elopement, as indicated by his Minimum Data Set and Elopement Evaluation. The resident's care plan identified him as at risk for wandering or elopement, with a goal to prevent him from leaving the facility unattended, but did not specify what triggers staff should monitor for. On the day of the incident, the resident was last seen in the dining room at 6:15 p.m. by a registered nurse, who then left him alone while the receptionist was at the front desk. The receptionist's desk did not provide a direct line of sight to the front door, and the front door alarm was not activated before 8 p.m., allowing the resident to leave the facility undetected. The resident was discovered missing at approximately 7 p.m., and was later found by a member of the public about 14 miles from the facility. Interviews with staff confirmed that the receptionist could not adequately monitor the front door from her position, and that the front desk should not be left unattended. The facility's policy required documentation of elopement risk and individualized interventions, but the care plan lacked specific details on triggers for wandering or elopement. The combination of inadequate supervision, lack of clear monitoring procedures, and insufficient environmental safeguards contributed to the resident's elopement.