Failure to Supervise Cognitively Impaired Resident Results in Elopement
Penalty
Summary
A cognitively impaired resident with diagnoses of Parkinsonism and unspecified dementia was admitted to the facility and initially assessed as not being at risk for elopement. However, after multiple attempts to leave the facility, the resident was placed on 15-minute visual checks. Despite this intervention, the resident was able to exit the facility without staff knowledge and walked approximately 1.3 miles away, where she was found by two unknown individuals and taken to a local hospital. The incident occurred while the resident was supposed to be under increased supervision due to her recent exit-seeking behavior. The failure to prevent the resident's elopement was due to several lapses in communication and procedure. Staff members responsible for the resident's care were not informed during shift reports that the resident was on 15-minute visual checks, resulting in the checks not being performed or documented. Additionally, the facility's 24-hour report sheets did not consistently include information about the resident's elopement risk or the need for visual checks. Multiple staff members, including nurses and CNAs, reported being unaware of the resident's status and did not perform the required monitoring. Compounding the issue, the facility's door alarm system was not effectively managed. Staff reported that the door alarm frequently sounded during visiting hours and was often reset without verifying the cause or checking on residents at risk for elopement. On the evening of the incident, a staff member reset the alarm after hearing it but did not investigate further or notify others, which may have allowed the resident to leave undetected. These combined failures in communication, documentation, and adherence to policy led to the resident's unsupervised exit and the resulting Immediate Jeopardy finding.