Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when a resident with a known high risk for elopement and exit-seeking behaviors was not adequately monitored or supervised, resulting in the resident leaving the facility unsupervised and without staff knowledge. The resident, who had a history of psychosis, cerebral infarction, suicidal behavior, falls, and anxiety disorder, was assessed as having no cognitive impairment but exhibited persistent behaviors of wanting to leave the facility. The care plan identified the resident as high risk for elopement, with interventions including distraction and redirection, but did not include physical monitoring or electronic alert systems at the time of the incident. On the day of the incident, the resident monitored the front door and used their motorized scooter to block the door from locking when a visitor entered, allowing them to exit the building undetected. The resident traveled over a mile on a two-lane highway in the dark, using a scooter without headlights or reflectors, before being found by an off-duty CNA. Staff interviews revealed that the resident had made several previous attempts to elope, and staff were aware of the resident's ongoing exit-seeking behaviors and verbalizations of wanting to leave, but no additional monitoring or supervision was implemented to prevent elopement. The facility's existing door alarm system was insufficient, as it could not be heard at the nurses' station, and the resident did not have a bracelet or other device to alert staff of an exit attempt. Staff were unaware of the resident's absence until notified by the off-duty CNA who found the resident in town. The resident did not sign out prior to leaving, and the facility's elopement and wandering policy required prompt identification and response to elopement risks, which was not followed in this case.