Failure to Supervise Resident Results in Unsupervised Exit and Elopement
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to ensure adequate supervision for a resident with a history of repeated falls, difficulty walking, pelvic fracture, and cognitive communication deficit. The resident's care plan required one-person staff assistance for ambulation, and there was no physician order for a leave of absence. Despite these requirements, the resident was able to exit the third floor via elevator, leave through the front entrance, and was not noticed missing until later in the shift. Facility documentation and staff interviews revealed that the nursing assistant assigned to the resident was told by the resident that they needed to walk, but the assistant assumed this meant walking on the unit. When the resident was later found missing, a Code Yellow was announced. Surveillance footage showed the resident, dressed appropriately and using a walker, leaving the building behind a group of visitors. The receptionist, who was distracted by personal activities on the computer, did not recognize the resident as a resident and allowed them to exit without following sign-out or visitor badge protocols. The resident was located approximately 1.2 miles away in a busy area after being missing for about two hours. The facility's investigation confirmed that the resident did not have a physician order for a leave of absence and should not have been allowed to leave unaccompanied. The failure to follow established protocols for supervision, leave of absence, and visitor management directly contributed to the resident's unsupervised exit and subsequent elopement.