Failure to Supervise Elopement Risk Resident Resulting in Unsupervised Exit
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as an elopement risk, resulting in the resident leaving the secured area unsupervised. The resident, who had diagnoses of Alzheimer's disease and dementia, was care planned for elopement risk with interventions such as reorientation, locked courtyard gate, diversional activities, and visual checks. Despite these interventions, the resident was able to exit through a courtyard gate that was found to be unlatched and unlocked, with the padlock hanging on the latch. Staff were unaware of how the gate became unlocked, and the resident was found outside the facility after ringing the doorbell to be let back in. At the time, staffing was limited, with only one LPN and one CNA present, both occupied with other duties. The resident had a documented history of wandering, exit-seeking behaviors, and previous attempts to leave with visitors. Multiple nurse notes indicated ongoing wandering and exit-seeking, including attempts to follow visitors out and requests to go outside. Staff interviews confirmed that the resident was not under direct supervision at the time of the incident, and the facility's elopement prevention policy required adequate supervision for residents at risk. The maintenance director, who had access to the gate key, was unavailable for interview, and management could not determine how the gate was unlocked.