Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision
Penalty
Summary
A resident assessed as high risk for elopement, with diagnoses including type 2 diabetes mellitus, epilepsy, and schizophrenia, was admitted to the facility and had a documented history of elopement or attempted elopement. The resident's care plan identified the risk for elopement and included interventions to identify triggers for wandering. Despite these assessments and interventions, the resident was able to leave the facility unassisted and without permission through the main entrance, while the receptionist, who was responsible for monitoring the lobby and preventing elopement, was present but did not notice the resident leaving. Video surveillance footage confirmed that the resident moved through various areas of the facility, including the hallway, patio, and lobby, before exiting through the main entrance. The receptionist was at the desk but was distracted by personal activities and did not observe the resident leaving. Staff interviews revealed that the whereabouts of the resident were not consistently monitored, with some staff not checking on the resident for several hours. The facility's policy required staff to monitor residents at risk for elopement and to intervene if a resident attempted to leave, but these procedures were not followed. The resident was not located for several hours, during which time scheduled medications for epilepsy, diabetes, and schizophrenia were missed. Staff became aware of the resident's absence only after a significant delay, and a search was initiated. The facility's Director of Nursing acknowledged that staff failed to provide adequate supervision and monitoring as required by the resident's care plan and facility policy.