Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to ensure the safety of a resident who eloped from the building. The resident, who had diagnoses including toxic encephalopathy and congestive heart failure, was admitted with a diet order for pureed texture and mildly thick liquids. On the day of the incident, a CNA notified a nurse that the resident was missing. A thorough search of the resident's room, the building, and staff rooms was conducted, but the resident could not be located. Facility management reviewed surveillance cameras and confirmed that the resident had left the building and was seen heading east. The resident was later found inside a local restaurant approximately 0.4 miles from the facility by the Administrator in Training. The restaurant staff had contacted emergency services due to the resident appearing confused. Upon return to the facility, the resident was medically assessed, including for aspiration risk due to consumption of non-thickened liquids. The Director of Nursing confirmed that the resident was not their own responsible party and reiterated the resident's dietary restrictions. The facility's policy states that residents have the right to a safe environment, but the lack of adequate supervision allowed the resident to leave the premises unsupervised.