Resident Elopement Due to Inadequate Supervision and Failure to Identify Elopement Risk
Penalty
Summary
A deficiency occurred when a resident with multiple medical and psychiatric diagnoses, including dementia, major depressive disorder, and an indwelling urinary catheter, was able to leave the facility undetected. The resident, who was admitted recently and had expressed a desire to go home, exited the building by following a group of visitors through the front door. The facility's video footage confirmed that the resident left his room, used the elevator to reach the ground floor, and exited alongside visitors while talking on the phone. At the time, the receptionist was occupied assisting other guests, and the electronic door system was used to allow the group to leave, enabling the resident to exit without staff intervention. The facility's policies required identification and care planning for residents at risk of wandering or elopement, as well as regular checks and documentation for those with elopement risk. However, the resident was not identified as exit-seeking or at risk for elopement upon admission, and his care plan did not include specific interventions for wandering or elopement prevention. Staff interviews revealed that the resident had been agitated and expressed a desire to leave earlier in the evening, and his wife had communicated this to the assigned LPN. Despite this, the resident was not under increased supervision, and staff only became aware of his absence after his wife reported that he had called her from outside the facility. Following the discovery of the resident's absence, staff initiated a Code Silver alert and conducted a search of the building and surrounding area. The resident's daughter arrived at the facility shortly after, reporting that he had safely arrived home, which was several blocks away. The incident was documented in the facility's records, and interviews with staff confirmed the timeline and circumstances of the resident's elopement. The event demonstrated a failure to provide adequate supervision and to ensure the area was free from accident hazards, as required by facility policy and regulatory standards.