Failure to Prevent Elopement and Neglect of Residents at Risk
Penalty
Summary
The facility failed to protect two residents identified as being at risk for elopement from neglect, resulting in serious harm to one resident. One resident, with severe cognitive impairment and multiple psychiatric and neurological diagnoses, was able to leave the facility unnoticed. This resident exited through a screened patio door, after removing part of the screen, and walked unsupervised for eight miles along high-traffic streets, eventually being found by the State Highway Patrol on an interstate highway. The resident was subsequently hospitalized for dehydration and acute kidney injury. Interviews and records revealed that the resident was known to wander, had a history of impulsivity and agitation, and was assessed as an elopement risk, but was allowed unsupervised access to an unsecured patio area. Staff were unaware of the resident's whereabouts for an extended period, and there was a delay in notifying law enforcement after the resident was discovered missing. Another resident, also with severe cognitive impairment and a history of wandering, was able to exit the facility through an emergency exit door. The alarm on the door was triggered, and the resident was found 10-15 feet from the building, attempting to leave. This incident was identified as an isolated event by the facility, but it demonstrated a failure to provide adequate supervision and secure the environment for residents at risk of elopement. Both residents had care plans indicating their elopement risk and interventions such as allowing safe wandering on secure units, but these interventions were not effectively implemented. Facility policies required the identification, assessment, and monitoring of residents at risk for elopement, as well as the maintenance and inspection of exit doors and alarms. However, the report documents lapses in staff supervision, communication, and adherence to protocols, including delayed notification of police and failure to secure areas accessible to high-risk residents. These failures resulted in one resident suffering serious harm and created the likelihood of serious injury or death.