Failure to Prevent Resident Elopement Due to Inadequate Supervision and Unsecured Exits
Penalty
Summary
The facility failed to prevent a resident with severe cognitive impairment and a known risk for elopement from leaving the premises on two separate occasions. The resident, who had diagnoses including dementia, abdominal aortic aneurysm, diabetes mellitus type 2, and hypertension, was assessed as an elopement risk and had care plan interventions such as additional supervision and activity engagement to divert exit-seeking behavior. Despite these interventions, staff documented multiple incidents of exit-seeking behavior prior to the elopements. On the first occasion, the resident left his room, ambulated to the front lobby, and exited through the front door without staff intervention until he was already outside on the sidewalk. Staff only responded after the resident was observed outside, and there was confusion regarding the overhead page, which was not clearly identified as an elopement. On the second occasion, the resident was last seen in his wheelchair in the hallway and subsequently exited through an unlocked and unalarmed door at the back of the facility. The gate leading off the property was also found unlocked and ajar. Staff initiated a search, and the resident was eventually located at a nearby grocery store, appearing tired and wobbly. Interviews with staff confirmed that the resident was recognized as a flight risk from admission and required frequent redirection. Staff reported that doors and gates were found unlocked and alarms were disabled at the time of the second elopement. Facility policy required preparedness and supervision to prevent such incidents, but these measures were not effectively implemented, resulting in the resident's unsupervised departures from the facility.