Failure to Prevent Elopement Due to Inadequate Supervision and Environmental Hazards
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of psychosis, toxic encephalopathy, and exit-seeking behavior eloped from the facility for the third time. The resident had previously eloped on two separate occasions, and each time, the facility implemented or continued 15-minute visual checks as the primary intervention. Despite being identified as high risk for elopement and having a care plan in place, the resident was not placed on 1:1 supervision, and the visual checks were inconsistently documented, with significant gaps and missing staff signatures on the monitoring logs. Multiple facility exit doors were found to be inadequately secured or alarmed. The main lobby door's wander guard system was routinely turned off during the day, and the code to unlock another exit was visibly written on the equipment. The kitchen/laundry access door and staff exit door lacked any alarm system and were sometimes left open, providing unrestricted access to the parking lot. Additionally, a side perimeter door was broken and unlocked, allowing entry and exit from both inside and outside the facility. Staff interviews confirmed awareness of these security lapses, and some staff expressed that the facility was not equipped to manage residents with significant mental health needs. On the day of the third elopement, the resident was noted to be confused and aggressive, and staff discovered a door open near the resident's room. The resident was not found during a facility search and was later located at a hospital after being missing for four days, having been admitted for sepsis and pneumonia. The facility's own policy required systematic monitoring and modification of interventions for residents at risk of elopement, but the interventions in place were not effective or consistently implemented, and environmental hazards were not addressed.