Resident Elopement Due to Inadequate Supervision and Exit Monitoring
Penalty
Summary
A resident with a known history of independently ambulating throughout the facility and using the elevator was able to leave the building without staff awareness. The resident was last seen around lunchtime using the elevator, and staff later discovered the resident was missing after a facility-wide search. The resident did not inform staff, did not sign out, and left without a physician's order. The facility has three entrances/exits, with the front entrance/exit open from 8 A.M. to 8 P.M., and some residents are allowed in the lobby area near this entrance. The back entrance/exit was reported to be locked. Interviews with staff revealed that the resident was considered independent and frequently roamed the building. The receptionist stated that they would be informed by a licensed nurse if a resident required supervision. The facility experienced three elopements in the past six months, with two occurring in the same month as this incident. The elopement occurred on a weekend when staffing was lower, and no staff member witnessed the resident leaving the building.