Failure to Follow Elopement Policy During Resident Smoking Break
Penalty
Summary
The facility failed to consistently follow its elopement policy and procedure, resulting in a resident leaving the premises unsupervised during a scheduled smoking break. The resident, who was alert and oriented but forgetful, ambulatory with a steady gait, and had diagnoses including schizophrenia, major depressive disorder, and nicotine dependence, was able to elope despite staff being present to monitor the smoking area. The area was not enclosed, and staff were required to have a walkie talkie and immediately notify management if a resident attempted to leave. However, the staff member monitoring the smoking break did not immediately inform management or initiate the required emergency response when the resident eloped, instead relaying the information in passing to the receptionist after the fact. The delay in notification resulted in a lack of immediate response to the resident's elopement. The resident was eventually returned to the facility by police and was noted to be physically and verbally aggressive and non-directable upon return. Facility policy required staff to attempt to prevent residents from leaving, seek help from other staff, and immediately inform the charge nurse or DON if a resident left or attempted to leave. These steps were not followed, placing the resident's health and safety at risk.