Resident Elopement Due to Inadequate Supervision and Exit Security
Penalty
Summary
A deficiency occurred when a resident was able to elope from the facility after a visitor used the exit code and held the door open, allowing the resident to leave the building unsupervised. The incident took place in the evening, and the resident was not discovered missing until routine rounds were conducted. Staff initiated a search of the facility and, upon failing to locate the resident, notified facility management and law enforcement. The resident was eventually found over three hours later, more than a mile from the facility, and was transported to the hospital for evaluation after reporting shortness of breath. The resident involved was an elderly female with a history of cerebral infarction (stroke), hypertension, aphasia, expressive language disorder, and difficulty walking. Her admission assessments indicated she was not considered an elopement risk, though she was at risk for falls. The resident was described as not very verbal and occasionally unable to express her needs, but able to respond to yes or no questions and aware of her surroundings. At the time of the incident, she was observed independently leaving her room, walking through the hallway, and exiting the facility after a visitor held the door open for her. Staff interviews revealed that the door code had previously been shared with visitors, and staff would often assist visitors in and out of the building. The elopement risk assessment for the resident had not identified her as a risk, and there was no indication of prior exit-seeking behavior. The facility did not have a locked unit or use a Wander guard system. The deficiency was identified as placing residents at risk for elopements, which could result in falls, injuries, dehydration, and hospitalization.