Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Elopement
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, delusional disorder, Parkinson's disease, and Alzheimer's disease, who was assessed as a high risk for wandering and elopement, exited the facility unsupervised. The resident had been actively exit seeking and displaying increased agitation and wandering behaviors for at least two days prior to the incident. Despite these behaviors, staff did not implement increased supervision or additional interventions beyond closing doors and attempting redirection. The resident was able to leave the facility through a dining room exit door, which led to a series of steep concrete stairs and a parking lot. On the night of the incident, staff observed the resident wandering the halls, testing doors, and expressing a desire to leave the facility. The resident was given PRN pain and anti-anxiety medications and was believed to be resting in bed shortly before the elopement. However, the resident managed to exit her room, traverse the facility, and open the dining room exit door, which triggered an alarm. Staff responded to the alarm and found the resident outside in the parking lot, having descended multiple flights of stairs without her walker, in cold weather conditions. Interviews with staff revealed that the resident had been exhibiting increased exit-seeking behaviors, including setting off door alarms and attempting to leave through various exits. Staff assignments and coverage were limited due to short staffing, and staff were not present on the resident's hall at the time of the elopement. The resident had a recent history of unwitnessed falls and was not considered safe to ambulate unsupervised, yet no increased supervision was implemented during the period of heightened exit-seeking behavior.