Failure to Prevent Resident Elopement and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unattended. The resident, who had diagnoses including dementia, metabolic encephalopathy, bipolar disorder, and unsteadiness, was found outside the building on the front porch in a wheelchair without staff supervision. Video footage confirmed that the resident exited through the front doors after visitors left, triggering the door alarm, but staff did not respond to the alarm. The resident was outside for several minutes before being brought back inside by the DON, and there was no immediate documentation of the incident in the resident's medical record. Further review revealed that the resident's care plan was not updated to reflect his exit-seeking behaviors, despite multiple documented instances of such behavior in the medical record. The social services department was unaware of the resident's elopement risk, and the resident was not included in the elopement risk binder. Staff interviews indicated that the resident was not safe to be outside alone, and that there was a lack of communication and documentation regarding his behaviors and risk status. Additionally, the facility failed to ensure that staff consistently signed out and carried pagers that would notify them of door alarms and resident call system activations. Several staff members did not have pagers during their shifts, and there were reports of insufficient pagers for all staff. This contributed to the lack of timely response to the door alarm when the resident exited the building. Facility policies required care plan updates and documentation of elopement risks and incidents, but these procedures were not followed in this case.