Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, dementia, aphasia, anxiety disorder, and major depressive disorder exited the facility without staff knowledge and walked 2.7 miles to a free-standing emergency department. The resident's wandering risk assessment, completed prior to the incident, indicated a low risk for elopement, and the comprehensive care plan noted the need for supervision and assistance with all decision-making due to impaired cognitive function. Staff interviews revealed that the resident was last seen in his room late in the evening, but was not accounted for during subsequent rounds, and his absence was not immediately reported to supervisory staff. The facility's staff did not notice the resident was missing until several hours after he had left the building. During this period, the resident was able to leave through an unknown door, which did not trigger an alarm, and was later found outside a hospital emergency room by a bystander. The resident was unable to communicate his intentions or the reason for his departure due to his aphasia and cognitive impairment. Staff interviews indicated that the resident had not previously displayed exit-seeking behavior, and the facility's criteria for high elopement risk did not identify him as such prior to the incident. The delay in recognizing the resident's absence and the lack of immediate notification to supervisory staff contributed to the failure to provide adequate supervision and prevent the accident. The facility's policies required staff to determine if a resident was on authorized leave, initiate a search if not, and notify appropriate parties if the resident could not be located. However, these procedures were not effectively implemented in this case, resulting in the resident's unsupervised exit and subsequent discovery at an external emergency department.