Failure to Prevent Elopement and Provide Adequate Supervision for At-Risk Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, specifically related to elopement risk. A cognitively impaired resident with multiple diagnoses, including chronic obstructive pulmonary disease, hemiplegia, diabetes, and depression, was assessed as a moderate risk for elopement and had a history of exit-seeking behavior. Despite these known risks, the resident's care plan did not include interventions to address elopement until after the resident had already left the facility without staff knowledge or supervision. The resident was able to exit through a smoking patio door, which was not kept secure, and the door alarm was dismissed by staff without a resident head count or further investigation, as required by facility policy. The incident occurred when the resident exited the facility during the night and was later found 2.2 miles away, standing on a concrete median by a stop light in the dark, expressing that he was cold. Staff interviews revealed that the nurse on duty heard the door alarm but assumed it was triggered by the wind and did not follow procedures to account for all residents, particularly those at risk for elopement. The resident was not discovered missing until several hours later when another staff member found him outside the facility. The resident required a walker, had impaired cognition, and was not safe to be outside unsupervised, especially at night and in cold weather. Additionally, another resident identified as high risk for elopement was observed without the required electronic sensor device or one-on-one supervision, despite care plan directives. Staff confirmed that this resident had not been provided with the necessary monitoring devices or supervision. The facility's elopement policy required immediate response to door alarms, investigation of the cause, and accounting for all at-risk residents, but these procedures were not followed, contributing to the deficiencies identified.