Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of schizophrenia, who had a history of delusions and behavioral issues, eloped from the facility without staff knowledge or authorization. The resident's care plan, which was revised shortly before the incident, identified behavioral risks related to schizophrenia and included interventions to anticipate the resident's needs. Despite these measures, the resident was able to leave the premises unsupervised. Interviews with facility staff revealed that the receptionist noticed the resident was missing from the front patio and subsequently notified other staff, but was unsure how long the resident had been absent. The Director of Nursing acknowledged both the risk of elopement due to the resident's mental health condition and the facility's responsibility to provide adequate supervision. Review of facility policy confirmed that residents at risk for elopement should receive appropriate supervision in accordance with their care plan, which was not effectively implemented in this case.