Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A resident with a history of traumatic brain injury, cognitive communication deficit, adjustment disorder, and difficulty in walking, who was under guardianship and identified as an elopement risk, was residing on a secured unit. The resident had a care plan in place indicating the need for supervision and interventions such as residing on a secure unit, structured activities, and safety supervision checks. Despite these measures, the resident made verbal statements expressing a desire to leave the facility. On the night of the incident, three staff members on the secured unit failed to recognize and appropriately respond to a sounding door alarm, which was triggered when the resident forcefully opened a locked and alarmed door leading to a fire escape. The staff mistook the alarm for a malfunction and did not investigate the source or check on the resident, despite the alarm continuing to sound for an extended period. The nurse on duty was unfamiliar with the unit's alarm system and was not aware of the resident's elopement risk or care plan. The resident was able to exit the unit, descend the fire escape, climb over a fence, and leave the facility grounds without staff knowledge. The resident's absence went unnoticed until the following shift, when staff were unable to locate the resident and notified facility leadership. The resident's whereabouts were unknown for approximately twelve hours until located by police in a bar several miles away. The failure to provide adequate supervision and to respond appropriately to the door alarm resulted in the resident's elopement and placed the resident at risk for serious harm.