Resident Elopement Due to Inadequate Supervision During Acute Delusional Episode
Penalty
Summary
A deficiency occurred when a resident with a history of unspecified psychosis, cerebral infarction, hypertension, adjustment disorder with depressed mood, weakness, and unsteadiness on her feet was not adequately supervised, resulting in her leaving the facility unsupervised. The resident, who had recently been admitted from the hospital and had a recent urinary tract infection and changes to her antipsychotic medications, exhibited acute delusions and agitation during the night. Despite being placed at the nurses station for monitoring due to her behaviors, staff supervision lapsed when a CNA left to answer a call light, and the resident was able to leave the facility in her wheelchair without being noticed. Staff interviews revealed that the resident was being checked every 15 minutes and was considered calm and not displaying exit-seeking behaviors prior to the incident. However, during a period when the CNA was away from the nurses station, the resident left the area and exited the building. The staff initiated a search and found the resident outside on the sidewalk, approximately 130 feet from the facility, fully dressed and in her wheelchair. The resident was returned to the facility without injury. The facility's records indicated that the resident was previously assessed as alert, oriented, and free from confusion, qualifying her for independent pass privileges. However, during the incident, she was experiencing acute cognitive changes, including delusions and agitation, which were not adequately addressed through increased supervision. The facility's elopement policy outlines procedures for searching and notification in the event of a missing resident, but the lapse in supervision allowed the resident to leave the facility unsupervised.