Failure to Provide Adequate Supervision for High Elopement Risk Resident
Penalty
Summary
A cognitively impaired resident with a history of cerebral infarction, substance abuse, and anxiety disorder, who was identified as high risk for elopement, exited the facility through a bathroom window. The resident had previously exhibited exit-seeking behaviors, including verbalizing a desire to leave, attempting to leave the facility, and requesting police assistance to return home. The care plan and physician orders indicated the need for elopement precautions, including hourly census checks and, following an incident of increased agitation, 1:1 staff supervision for safety. On the morning of the incident, the resident was observed to be calm during breakfast and did not display abnormal or exit-seeking behaviors according to staff interviews. The nurse practitioner, after assessing the resident and finding him cooperative, lifted the 1:1 supervision order. Shortly after, staff were unable to locate the resident, and a search of the facility revealed that he had left through a bathroom window. Surveillance footage confirmed the resident's last known location in the bathroom, and staff initiated a facility-wide search upon realizing his absence. The resident was later found by local police approximately half a mile away, having been involved in the theft of a motor vehicle. The police report indicated that the resident was attempting to travel to his home and was subsequently taken into custody. The facility's failure to maintain adequate supervision and implement effective elopement precautions for a resident at high risk for elopement resulted in the resident leaving the premises without authorization and created an immediate jeopardy situation.