Failure to Prevent Elopement for Resident with Psychiatric History
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and monitoring to prevent elopement for a resident with a known history of exit-seeking behaviors and psychiatric diagnoses, including paranoid schizophrenia. The resident was identified as being at risk for elopement, with a care plan in place that included one-on-one supervision and redirection during exit-seeking episodes. Despite these documented interventions, the resident was observed attempting to exit the facility around 2 AM and was redirected by a CNA, who then notified the nurse on duty. However, no additional interventions were implemented following this incident, and the resident was not placed on increased supervision or monitoring. Later the same morning, during shift change, the resident successfully exited the facility through a door that triggered an alarm. Multiple staff members responded and searched for the resident, who was eventually found hiding in a metal cargo container on the property approximately 15 minutes after leaving the building. Staff interviews revealed that the resident was able to leave the facility unobserved, and there was confusion among staff regarding notification procedures and the implementation of the care plan interventions. Statements from staff indicated that not all required notifications were made, and there was a lack of clarity about who was responsible for monitoring the resident after the initial exit-seeking attempt. The resident was subsequently returned to the facility and sent to the hospital for evaluation, where he was diagnosed with behavioral disturbances related to his psychiatric conditions. Documentation and interviews confirmed that the facility did not implement resident-centered interventions after the initial exit-seeking behavior, nor did they ensure that all staff were aware of and following the care plan. The failure to provide adequate supervision and to act on known risk factors resulted in the resident's elopement and subsequent hospitalization.