Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide necessary supervision to prevent an elopement for one resident who was assessed as being at risk for wandering and elopement. The resident, who had impaired memory and required assistance to walk safely, was documented as wandering in the nursing unit and was redirected from the front desk/lobby area twice by staff. Despite these interventions, the resident was not observed on the unit, and it was discovered that they had exited the facility through the front door and were seen walking on a busy street outside. The resident was found approximately a block away from the facility. Interviews with staff and review of records confirmed that the resident had a history of wandering and elopement risk, as indicated in the initial admission elopement risk assessment. Staff acknowledged that the resident did not receive the level of supervision required to prevent them from leaving the building. The facility's elopement policy required assessment for exit-seeking and wandering behaviors, but the necessary supervision was not maintained, resulting in the resident's unsupervised exit.