Failure to Prevent Resident Elopement Due to Inadequate Risk Assessment and Security
Penalty
Summary
The facility failed to prevent multiple incidents of resident elopement due to inadequate recognition of elopement risk, failure to secure exit doors and gates, and insufficient supervision. Three residents with cognitive impairments and histories of wandering or elopement were able to leave the facility on several occasions. Staff did not consistently identify or document residents' elopement risk, and elopement assessments were either incomplete or not updated after incidents occurred. For example, one resident with dementia and muscle weakness had a documented history of exit-seeking behavior, but staff failed to document interventions or clinical suggestions on her elopement evaluation. Interviews with staff confirmed that this resident frequently attempted to leave and would follow others out of the facility if not closely monitored. Physical security measures were also lacking. Exit doors and exterior gates, including those in the dining room and south courtyard, were found to be either malfunctioning or left unsecured. Maintenance staff admitted that the south courtyard gate was routinely left unlocked during the day and only secured at night, and that the padlock was not always used. After one resident was found outside in the parking lot, the administrator instructed maintenance to secure the gates, but prior to this, the area was accessible and unsafe for residents. The lack of proper supervision and environmental controls led to multiple elopements. One resident with end-stage renal failure, diabetes, and cognitive impairment eloped multiple times, including an incident where she was missing for approximately 30 hours and was later hospitalized for emergency dialysis, dehydration, and sunburn. Another resident with dementia and psychiatric diagnoses left the facility with a peer, and staff failed to update elopement assessments or care plans after these events. Staff interviews revealed that there was a general awareness of residents' exit-seeking behaviors, but appropriate risk assessments, documentation, and immediate interventions were not consistently implemented.