Resident Elopement Due to Inadequate Supervision and Unsecured Gates
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement risk and severe cognitive impairment was able to leave the facility and its grounds without staff knowledge. The resident, who had diagnoses including mild dementia with agitation and major depressive disorder, was identified as an elopement risk in both his care plan and elopement evaluation. On the day of the incident, the resident was last seen sitting outside on the porch during a smoke break with other residents. After the other residents were escorted inside, staff did not notice that the resident remained outside. He subsequently exited the facility grounds through an unsecured gate and was found by a non-employee approximately one eighth of a mile away from the facility. Facility records and staff interviews confirmed that the outside gates surrounding the smoking patio area were not secured and could be easily opened. The Director of Nursing acknowledged that all three gates were unsecured at the time of the incident and confirmed the resident's elopement. The resident was returned to the facility without injury, but the event substantiated a failure to provide adequate supervision and to ensure the environment was free from accident hazards, as required by the facility's own elopement management policy.