Failure to Provide Required Supervision Resulting in Resident Elopement
Penalty
Summary
A resident with diagnoses including dementia, alcohol abuse, and frontotemporal neurocognitive disorder, who resided on a secured memory care unit, was identified as being at risk for elopement and was placed on one-to-one staff supervision due to exit-seeking behaviors. Despite this intervention, the resident was able to exit the facility through a window in another resident's room. The window led to a secured courtyard, from which the resident used a chair to climb over a six-foot privacy fence and subsequently left the premises. The resident was later found by staff approximately two miles from the facility. On the day of the incident, the staff member assigned to provide one-to-one supervision for the resident was reassigned to perform general duties with other residents due to staffing shortages. As a result, the resident did not receive the required one-to-one supervision during the day shift. Multiple staff interviews confirmed that the resident was not under direct observation at the time of the elopement, and some staff were unaware that the supervision had lapsed. The resident had a documented history of exit-seeking behavior, including a previous incident where he left the facility through a window and walked to a grocery store. Observations and interviews revealed that the resident was able to manipulate the window hardware, remove screws, and exit through the window without staff detection. The facility's elopement prevention policy defined elopement as leaving the premises or a safe area without authorization or necessary supervision. The failure to provide the required supervision allowed the resident to leave the secured unit and the facility, resulting in the deficiency cited by surveyors.
Removal Plan
- audits of elopement evaluations and care plans
- inservicing staff on elopement procedures and one-to-one staff supervision
- ongoing monitoring