Failure to Provide Adequate Supervision and Maintain Secured Exits for Resident at Risk of Elopement
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident identified as an elopement risk, resulting in two separate incidents of elopement. The resident, who had a history of wandering behavior for at least four years and wore a wander guard bracelet, was able to exit the building on two occasions. In the first incident, the resident was observed multiple times attempting to open a Sunroom exit door. Staff redirected the resident several times but left the area unattended despite knowing the door's alarm system was not functioning due to a loose power connection. The resident ultimately managed to open the unsecured door and leave the building without staff witnessing the exit, and the alarm did not sound as required by facility policy. In the second incident, the same resident exited the building through a different door (Smoker's exit) that was equipped with an alarm. The alarm functioned properly, alerting staff, who then located and redirected the resident back inside. However, staff interviews revealed that the resident had made multiple attempts to elope that evening, and there were only three staff members present, which was insufficient to provide adequate supervision for the resident's known exit-seeking behavior. Additionally, the Charge Nurse failed to immediately notify the DON or Administrator of the elopement, contrary to the facility's Elopement and Wandering Policy. Both incidents demonstrate that the facility did not follow its own policies regarding secured exits and immediate notification of elopements. The failure to ensure that exit alarms were functioning and to provide adequate supervision for a resident with a known risk of elopement directly led to the resident being able to leave the facility on two occasions.