Failure to Supervise and Respond to Elopement Risk
Penalty
Summary
A deficiency occurred when staff failed to provide an environment free from accident hazards and did not ensure adequate supervision for a resident at risk for elopement. The resident, who had a diagnosis of frontal temporal neurocognitive disorder and was assessed as an elopement risk, was supposed to be monitored with 15-minute safety checks due to inappropriate behaviors. On the night in question, the assigned CNAs and LPN did not perform or document these checks as required by facility protocol. Video surveillance later confirmed that the checks were not conducted, despite documentation indicating otherwise. At approximately 8:14 p.m., the resident exited the facility by riding the elevator from the fourth floor to the first floor, opening the front door, and leaving the building. The door alarm was triggered, but the staff member who heard the alarm only looked out a window, did not see anyone, and failed to search the area or notify others. The alarm was reset without further investigation. The absence of the resident was not discovered until nearly eight hours later, at around 4:00 a.m., when a CNA noticed the resident was missing. The LPN was notified, but the NHA was not informed until over two hours after the resident was found to be missing. The resident was found by police approximately 12 hours after leaving the facility, sitting on a curb in a neighborhood, confused and unable to recall the events during his absence. The resident was taken to a hospital for evaluation and was found to have no injuries. The failure to conduct required safety checks and to respond appropriately to the door alarm directly led to the resident's elopement and prolonged absence from the facility.