Resident Elopement Due to Failure in Supervision and Door Security
Penalty
Summary
A deficiency occurred when a newly admitted resident with diagnoses of unspecified dementia and altered mental status was able to exit the facility unsupervised and unmonitored. The resident left through the front door after the receptionist, not recognizing her as a resident, unlocked the door. No staff or visitors were present to intervene as the resident exited. The resident was subsequently found sitting on the back of a trailer attached to a pickup truck in the middle of a busy intersection approximately 600 feet from the facility, surrounded by several cars. Multiple staff members, including nursing and administrative personnel, responded to retrieve the resident, who was combative and resistant to returning to the facility. Interviews with staff revealed that the incident occurred during a shift change, and several staff members, including LPNs, the DON, ADON, and the Administrator, did not witness the resident leaving the building but responded after hearing staff yelling about the resident's elopement. The receptionist admitted to unlocking the door for the resident, stating she did not recognize her due to the resident's recent admission. The admissions coordinator and nursing staff did not identify any significant concerns in the preadmission documents, although the resident's daughter had mentioned increased difficulty managing her at home. The social services director had not yet updated the wandering risk binder to include the new resident, as she was off work at the time of admission and had planned to complete the assessment the following day. The facility's policy on abuse, neglect, and exploitation prohibits acts of neglect, defined as the failure to provide necessary services to avoid physical harm. The resident's elopement and exposure to a hazardous situation in a busy intersection constituted a failure to protect her from neglect. The initial assessment of the resident upon return revealed no injuries, but the event was determined to be Immediate Jeopardy and Substandard Quality of Care due to the risk of serious harm.