Failure to Prevent Elopement Due to Inadequate Supervision and Exit Door Security
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure the proper functioning of an exit door, resulting in a resident eloping from the premises. The facility's policy on elopement protocols requires all staff to report any resident attempting to leave or suspected of being missing, and defines elopement as leaving the grounds of the nursing home. Despite this, a resident with a history of cerebral infarct, altered mental status, cognitive impairment, and daily wandering behaviors was able to exit the facility unsupervised. The resident's care plan identified him as an elopement risk due to disorientation and impaired safety awareness, with documented behaviors of attempting to leave the facility and trying to use door codes. On the day of the incident, staff last observed the resident in the hallway in the morning, but he was later found missing when a nurse went to administer medications. Staff searched for the resident, who was eventually found by the roadside by members of the public after he had fallen. The resident was transported to the hospital and later reported that he had left to go to a store, though he did not recall the incident during a subsequent interview. Interviews with staff revealed that the exit door at the end of the hallway, which the resident used, was not properly secured at the time of the incident. The maintenance director stated that he regularly checked the doors and changed codes, but acknowledged that residents observed staff entering codes and shared this information. Multiple staff members confirmed that the resident frequently checked doors to see if they were open, and housekeeping staff were instructed to ensure doors were locked when taking out the trash. The failure to provide adequate supervision and ensure the exit door was functioning properly directly contributed to the resident's elopement.