Failure to Prevent Resident Elopement Due to Inadequate Supervision and Documentation
Penalty
Summary
A deficiency occurred when a male resident with severe cognitive impairment and a high risk for elopement, as documented in his care plan and elopement assessment, was able to leave the secured unit and exit the facility without staff detection. The resident, who had dementia with behavioral disturbance and a history of wandering, followed a contract worker out of the secured unit during a period of construction and subsequently exited the building. Staff interviews and record reviews revealed that the door to the secured unit was not properly monitored, and there was no staff member specifically assigned to watch the door during the construction activities, despite the increased risk. The incident was further compounded by a lack of proper documentation and communication among staff. There was no incident or accident report for the elopement in the electronic record, and nurse's notes for the day of the incident were missing. Staff interviews indicated confusion about the timeline and responsibilities, with some staff unaware of the resident's absence until after he had left the facility. The Director of Nursing (DON) and Administrator acknowledged failures in documentation and investigation, including not taking statements from all relevant staff and not maintaining head count forms as required by facility policy. The facility's investigation confirmed that the resident was missing for approximately two hours before being found by police nearly a mile away. The lack of supervision at the secured unit door, inadequate staff training or understanding regarding door security during construction, and insufficient documentation and follow-up all contributed to the resident's ability to elope. These failures resulted in the identification of an Immediate Jeopardy situation due to the potential for serious harm.