Failure to Provide Adequate Supervision for Resident at Risk of Elopement
Penalty
Summary
A resident with a history of cerebral infarction, encephalopathy, stimulant abuse, and schizophrenia was admitted to the facility with severely impaired cognition, as indicated by a BIMS score of 3. The resident was identified as an elopement risk and exhibited behaviors such as wandering, agitation, rejection of care, and attempts to leave the facility. Multiple clinical notes documented frequent wandering, unsteadiness, agitation, and verbal expressions of wanting to leave. The care plan and wander risk assessments recognized the resident's risk for elopement, but despite these documented risks, the resident was not placed on a secured unit prior to the incident. Staff interviews revealed that the resident was known to be a 'runner' and was closely watched by staff, but there were lapses in supervision. On the day of the incident, the resident was highly agitated and expressed a desire to leave. The resident's wheelchair was later found outside the facility's front doors, and a search determined that the resident had eloped and was found at a nearby bus stop. The receptionist, responsible for monitoring the front door, did not observe the resident leaving, and the facility's policy required that at-risk residents be accompanied by staff or a responsible party when leaving the grounds. Despite staff awareness of the resident's behaviors and risk factors, the resident was able to exit the facility unsupervised. The facility did not implement additional interventions, such as transferring the resident to a secured unit, prior to the elopement, even though staff had discussed this option. The deficiency resulted from the failure to provide adequate supervision and to follow established policies for residents at risk of elopement.