Failure to Prevent Resident Elopement Due to Inadequate Supervision and Environmental Security
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. Two residents with severe cognitive impairment and a history of wandering or elopement risk were able to leave the facility unsupervised. One resident, who had dementia and was assessed as high risk for elopement, exited the secured unit courtyard through an unlocked gate after lawn care services had been performed. The resident was found by a community member at a nearby doctor's office and returned to the facility. Staff interviews and observations revealed that the gate required manual relocking after use, and staff were responsible for ensuring it was secured, especially after vendors such as lawn care services accessed the area. Another resident, also with severe cognitive impairment and a history of attempts to leave the facility, exited through the front door by following a family member who did not close the door behind them. This resident was found by a passerby at a nearby intersection and returned to the facility. Review of surveillance footage and staff interviews confirmed that the resident left the building during a period when staff were in a meeting and was not immediately noticed missing. The resident's care plan indicated interventions for wandering, but these were not effective in preventing the elopement. Record reviews and staff interviews indicated inconsistent practices regarding the monitoring and securing of exit doors and gates. Staff were expected to check the gates and doors at regular intervals and document these checks, but documentation was missing for certain periods. There was also confusion among staff regarding the procedures for relocking gates and the use of emergency exit buttons. The facility's elopement policy required prompt investigation and search for missing residents, but lapses in supervision and environmental security allowed two residents to leave the premises unsupervised.