Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and ensure a safe environment when a resident with idiopathic peripheral autonomic neuropathy and significant burn injuries eloped from the facility. According to the resident's routine, they would typically come to the nurse's station early in the morning to request medication, but on the day of the incident, the resident did not appear as expected. The RN searched the resident's room and surrounding areas, and after being unable to locate the resident, initiated a code green to alert staff of a missing resident. Subsequent attempts to contact the resident by phone revealed that the resident had left the facility and did not intend to return. Further review indicated that the resident later returned to collect personal belongings and signed an AMA (Against Medical Advice) form before leaving again. The Administrator acknowledged that the facility was responsible for resident safety and stated that the resident was able to leave unnoticed when a pharmacy technician failed to close the door upon exiting. The facility's policy emphasized the importance of a safe environment and adequate supervision, including addressing risks such as unsafe wandering, but these measures were not effectively implemented in this instance.