Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a resident assessed as high risk for elopement. The resident, who had diagnoses including Wernicke's encephalopathy, repeated falls, unspecified dementia, somnolence, and alcohol dependence, was known to exhibit exit-seeking behaviors and had verbalized a desire to leave the facility. Despite being identified as a high elopement risk and having a care plan in place, the resident was able to leave the facility unnoticed through the front door. On the day of the incident, the resident exited the building at 3:42 p.m. without staff awareness. The absence was not discovered until approximately two hours later, at which point staff initiated a search inside and outside the facility. The local police, the nursing home administrator, and the director of nursing were notified several hours after the resident's disappearance. The resident was ultimately found at a hospital emergency room nearly ten hours after leaving the facility, having traveled approximately five miles and sustaining abrasions to multiple areas of the body. Interviews and record reviews confirmed that the resident had a history of severe cognitive impairment, frequent wandering, and behavioral disturbances, including agitation and restlessness. The resident had previously demonstrated exit-seeking behavior by pushing on the front door and had required one-to-one supervision at times. On the day of the elopement, the front desk receptionist, whose duties included monitoring the front door, was temporarily away from the desk assisting ambulance workers, during which time the resident left the facility. The facility's failure to maintain adequate supervision and monitoring directly resulted in the resident's elopement and subsequent injuries.