Failure to Provide Required Supervision for Resident at Risk of Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident who was identified as an elopement risk. The resident, admitted with diagnoses including encephalopathy and anoxic brain damage, had a care plan in place that required constant monitoring and a one-to-one sitter due to impaired cognition and poor safety awareness. Despite these documented needs and interventions, the resident was left unsupervised at the facility's front entrance when the assigned staff member temporarily assisted another resident. During this period, the resident eloped from the facility and was later found at their home, 6.4 miles away. Interviews with facility staff confirmed that no one-to-one sitter was provided on the day of the incident, despite the care plan and prior assessments indicating this was necessary. The facility's policies on wandering, elopement, and resident supervision emphasized the importance of identifying at-risk residents and providing appropriate supervision, but these were not followed in this case. The deficiency resulted from the facility's failure to implement required supervision and safety measures for a resident at high risk for elopement.