Failure to Prevent Resident Elopement Due to Inadequate Supervision and Lacking Care Plan Interventions
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent a resident from exiting the building unsupervised. The resident had a history of nontraumatic brain dysfunction, dementia, anxiety, depression, and psychotic disorder, and was assessed as having impaired decision-making skills and confusion, despite an MDS score indicating intact cognition. The care plan did not include interventions for wandering or elopement prior to the incident, although it did note the resident was a fall risk and required alarms for bed and chair mobility. On two separate occasions, the resident was able to leave the facility without staff awareness. In the first incident, the resident exited through unlocked double doors in a wheelchair while a maintenance staff member briefly left the room. The resident was later found outside on the sidewalk near a generator and was brought back inside by staff. In the second incident, the resident again exited the building, this time by kicking open a west door, and was found outside on the grass by a CNA taking out the trash. In both cases, the resident was unsupervised outside the facility for a period of time before being located and returned by staff. Observations and staff interviews confirmed that the doors used by the resident did not lock from the inside and that the resident's care plan lacked specific interventions for elopement risk prior to these events. The facility's elopement policy required identification and precautions for residents at risk, but these measures were not implemented for this resident before the incidents occurred.