Failure to Monitor and Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for a resident with schizophrenia and moderate cognitive impairment, resulting in the resident leaving the facility without staff knowledge. The resident was admitted with a diagnosis that included the need for assistance with personal care and was determined to lack capacity to make healthcare decisions. Orders indicated the use of a wander guard device due to poor safety awareness, with instructions for staff to check its placement every shift. However, the resident had a known history of removing the wander guard, and staff interviews confirmed that the elopement risk assessment was not completed upon admission as required by facility policy. On the day of the incident, staff discovered the resident missing during routine checks and initiated a search, but the resident could not be found within the facility. The care plan documented the resident's tendency to wander and desire to leave, as well as previous episodes of removing the wander guard. Facility policies required elopement risk assessments for residents with cognitive impairment or a history of wandering upon admission, but this was not completed. The lack of timely assessment and monitoring contributed to the resident's unsupervised exit from the facility.