Failure to Prevent Resident Elopement Due to Inadequate Supervision and Communication
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident with a history of Parkinsonism, urinary tract infection (UTI), and cognitive communication deficit. The resident, who was moderately cognitively impaired and used a motorized wheelchair, exhibited confusion and exit-seeking behaviors on the night prior to the incident, including attempts to leave the facility and searching for his keys and truck. Staff attempted to redirect him and involved family members, but did not implement increased supervision or remove the motorized wheelchair at that time. On the morning following these behaviors, the resident again attempted to leave the facility through an unlocked service door, and staff redirected him back inside. However, this incident was not clearly communicated up the chain of command, and no additional supervision or interventions were put in place. Later that afternoon, the resident successfully eloped from the facility in his motorized wheelchair and traveled to a local church approximately 0.17 miles away. Facility staff were unaware of his absence until notified by a community member, at which point the resident was retrieved and assessed for injuries. Interviews with staff revealed a lack of clear communication regarding the resident's exit-seeking behaviors and attempts to leave the facility. Several staff members, including CNAs and LVNs, were aware of the resident's confusion and attempts to exit, but these incidents were not consistently reported to nursing leadership or acted upon with increased supervision. The facility's policies required staff to report such behaviors and implement interventions, but these steps were not followed, resulting in the resident's unsupervised elopement.