Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with profound cognitive impairment and a history of elopement, who resided on a locked unit and required 24/7 supervision, was able to leave the facility without staff knowledge. The resident had a severe traumatic brain injury, lacked decision-making ability, and was identified as being at high risk for elopement, as documented in their hospital discharge summary, care plan, and elopement risk evaluation. The care plan included interventions such as monitoring a wanderguard, promptly answering door alarms, and keeping the guardian informed. On the day of the incident, the resident participated in an outdoor activity in the facility's parking lot to pet baby goats. During this activity, the activity director left the area to escort another resident back to the locked unit and asked the activity assistant to supervise the remaining residents, including the high-risk resident. The activity assistant, who was responsible for multiple residents, was not able to provide adequate supervision and did not notice when the resident left the area. The resident was later found by police on a busy street approximately a half mile from the facility. Interviews with staff, including the activity director, activity assistant, nursing assistant, LPN, and others, confirmed that the resident required close supervision due to impulsivity, mobility, and a tendency to elope. Staff acknowledged that the root cause of the incident was a lack of adequate supervision, particularly when responsibility for the resident was transferred between staff members. The facility's elopement policy required interventions for residents at risk, but these were not effectively implemented during the outdoor activity, resulting in the resident's unsupervised departure from the facility.