Failure to Prevent Elopement Due to Inadequate Supervision and Staffing
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with moderate cognitive impairment and a diagnosis of dementia. The resident resided in the memory care unit and had a documented risk for elopement, as indicated in their care plan and elopement risk evaluation. Despite recent behavioral changes, including increased agitation and a statement about needing to leave due to a family event, no new interventions were implemented to address these behaviors. On the day of the incident, staffing records showed that only one of the two assigned CNAs was present in the memory care unit at the start of the shift, with the second CNA arriving over an hour late. Staff rounds were conducted, and the resident was observed pacing in the sunroom shortly before the elopement. Staff communicated the need for increased observation, but the resident was able to exit the building by climbing out of a sunroom window, which was found open with the screen removed. The resident was subsequently found two blocks away from the facility on a busy road by a staff member who had just left the facility. Interviews with staff revealed inconsistent understanding of elopement risk identification and supervision protocols. While some staff indicated that all ambulatory residents in the memory unit were considered at risk, others relied on administrative communication for risk identification. The administrator confirmed that the resident exited through a window and that rounds were typically conducted every two hours, which may not have been sufficient given the resident's recent behavioral changes and the staffing shortage at the time.