Failure to Provide Protective Oversight and Supervision for Elopement Risk Resident
Penalty
Summary
A facility failed to provide protective oversight and a safe environment for a resident who was assessed as an elopement risk, had a history of previous elopement, and resided on a secured behavioral unit. Staff allowed the resident into an exterior courtyard unsupervised and did not ensure the door was securely latched when the resident returned inside. The resident subsequently exited through the unlatched door, climbed onto the roof using a punching bag base, and left the premises without staff knowledge. Video footage confirmed the resident was unsupervised in the courtyard and used objects in the environment to facilitate elopement. Staff failed to complete required hourly face checks on the resident from 7:30 P.M. until approximately 11:30 P.M., as mandated by facility policy for residents at risk of elopement. Documentation of these checks was missing, and staff interviews revealed confusion and lack of awareness regarding responsibility for monitoring the resident. The charge nurse was not informed of the resident's change in behavior or the incident in the courtyard, and staff did not recognize or respond to the resident's increased agitation and delusional state earlier in the evening. The resident was missing for over 12 hours before being located by staff. The resident had a complex psychiatric history, including diagnoses of PTSD, antisocial personality disorder, bipolar disorder with psychotic features, schizoaffective disorder, and a history of substance abuse. The resident had demonstrated treatment non-adherence, delusional thinking, and a desire to leave the facility, all of which were documented in the medical record and care plan. Despite these known risks, the facility did not implement or follow adequate supervision and monitoring protocols, resulting in the resident's elopement.