Failure to Prevent Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of wandering and moderate cognitive impairment was not adequately supervised, resulting in the resident eloping from the facility. The resident had diagnoses including nontraumatic acute subdural hemorrhage, type two diabetes mellitus, and vascular dementia, and was identified as being at risk for wandering and elopement in the care plan. Interventions listed in the care plan included identifying the resident's room and bathroom, following protocols for wandering tendencies, keeping the resident's photo at nursing stations and the front entrance, and moving the resident to the second floor. Despite these interventions, the resident was able to leave the facility unnoticed. On the day of the incident, the resident was last seen by staff between 08:30AM and 09:00AM, and was later found missing at 09:20AM, prompting a code pink and a search. The resident was eventually located outside the facility in a nearby soccer field by an EMT, with no injuries noted. Staff interviews revealed that the resident had been observed pacing and lingering in the hallway earlier that morning, and had expressed a desire to leave. The LPN assigned to the resident reported seeing him near the nurses' station shortly before he was discovered missing, and staff at the front desk did not observe the resident leaving the building. The facility's Director of Nursing stated that the facility is not specifically set up for residents with wandering tendencies, but interventions are put in place for those identified as at risk. The DON also noted that the resident had not previously demonstrated exit-seeking behavior during his stay, although he had a history of elopement from a prior facility. The facility's policy requires behavioral assessment and monitoring, and for staffing needs to be evaluated based on resident acuity and care plans, but these measures did not prevent the resident's elopement in this instance.