Failure to Prevent Elopement Due to Unsecured Exit
Penalty
Summary
A deficiency occurred when a resident with a history of paranoid schizophrenia, sick sinus syndrome, cardiac pacemaker, and anxiety, who was assessed as being at risk for elopement and had a physician's order for a wander guard device, was able to leave the facility unsupervised. The resident's care plan documented previous attempts to leave the building without an escort, and the elopement risk assessment indicated wandering behavior. Despite these documented risks and interventions, the resident was able to exit through an unsecured sliding door in the conference room, which had been left unlocked by a contractor. The resident was discovered missing after staff noticed the wheelchair in front of the open conference room door. A facility-wide search confirmed the resident was the only one missing, and the elopement protocol was initiated. The resident was later found asleep on the grass approximately 0.6 miles away, having crossed a busy roadway. The resident was missing for 1 hour and 23 minutes before being returned to the facility. The incident was determined to be immediate jeopardy due to the failure to provide adequate supervision and secure assistive devices to prevent elopement.