Resident Elopement Due to Inadequate Supervision and Lack of Door Alarms
Penalty
Summary
A deficiency occurred when a resident left the facility unnoticed and remained missing for over 24 hours, resulting in the resident not receiving nursing care and being exposed to an unsafe environment. The resident, who had diagnoses including congestive heart failure, type II diabetes mellitus, and schizoaffective disorder, was assessed as cognitively intact. On the day of the incident, the resident was last seen in her room in the morning and was later observed by staff walking toward the front of the facility with her walker and personal belongings. Despite being seen by a CNA, the staff member did not follow or report the resident's departure, assuming others were aware. The facility's front door was not alarmed, and the resident was able to exit without staff intervention. The resident spent the night outside, sleeping in front of a library, and was returned to the facility the following evening by a neighbor. Upon return, the resident was found to be tachycardic, confused, and dehydrated, requiring emergency room evaluation and fluids. Interviews with staff revealed that the resident had asked for the facility's address and phone number prior to leaving, and that supervision was sometimes needed due to fall risk. The facility's policies required a safe environment and supervision to prevent elopement, but these were not followed, resulting in the resident's unsupervised exit and prolonged absence.