Failure to Prevent Elopement and Provide Adequate Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to accurately assess, identify, monitor, and supervise a resident at risk for elopement, resulting in the resident leaving the facility unsupervised and sustaining harm. The resident, who had a history of stroke, dementia, and encephalopathy, was documented as requiring staff assistance for activities of daily living and was noted in the care plan to be at risk for falls and injury due to cognitive loss and lack of safety awareness. Despite these documented risks, the resident was able to exit the facility without staff knowledge or intervention. On the day of the incident, nursing notes indicated that the resident had previously expressed a desire to leave and had shown signs of confusion and attempts to leave the facility. The resident was last checked on in their room in the early afternoon, and when staff later noticed the resident was missing, there was a delay in initiating a search. Staff were unclear about which residents were allowed to leave and did not immediately begin looking for the missing resident. Additionally, staff in the reception area did not notice the resident leaving the building. The resident was subsequently found by bystanders on a freeway ramp after having fallen and sustained injuries, including abrasions and bruising. Emergency services were called, and the resident was transported to the hospital, where it was determined that facility staff were not aware the resident was missing until contacted by the hospital. The facility's own investigation identified issues with the accuracy of the elopement risk assessment, delays in searching for the resident, and lack of familiarity among reception staff with the residents.