Failure to Supervise Resident with Exit-Seeking Behaviors Resulting in Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a known history of attempting to leave the facility unsupervised. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 12, was able to walk 50 feet with minimal assistance and had previously demonstrated exit-seeking behaviors, including leaving the facility and expressing a desire to go to Mexico. Staff interviews confirmed that the resident frequently attempted to leave, set off door alarms, and packed belongings in preparation to exit, with these behaviors occurring approximately every two weeks. Despite these known behaviors, staff did not consistently report the resident's actions to nursing staff as required. On the date of the incident, the resident was discovered missing during a staff lunch break, and after a search of the facility, the police were notified. The resident was subsequently found by police next to a neighboring church. Review of facility policy indicated that residents at risk for elopement should be assessed and have person-centered interventions implemented and communicated to staff, with ongoing monitoring by charge nurses and unit managers. However, the lack of timely reporting and intervention allowed the resident to elope without staff knowledge, resulting in a deficiency related to supervision and accident prevention.