Failure to Supervise and Prevent Elopement for At-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident at risk for elopement. The resident, admitted with a diabetic foot ulcer and cellulitis, had a documented history of elopement or attempted elopement at home. Despite this, the elopement evaluation did not identify risk factors or suggest interventions. Staff observed the resident attempting to leave the facility and placed a wander guard bracelet on him, but there was no clear documentation of who ordered or applied the device, and no corresponding assessment, care plan, or physician order was completed as required by facility policy. The resident was able to remove the wander guard and exit the facility in his wheelchair without staff knowledge. He traveled to a nearby gas station, crossing a highway with the assistance of bystanders, before being located and returned by staff and family. Interviews confirmed that staff were unaware of the resident's whereabouts until after he had left, and the incident was not immediately reported to the administrator. The resident was found without injury, but the lack of supervision and failure to follow established protocols for elopement risk contributed to the deficiency.