Failure to Prevent Elopement and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and oversight for residents with a known risk of elopement, resulting in multiple incidents where residents left the premises without staff awareness. One resident with a history of elopement was left unsupervised in the courtyard during a smoking break and used a chair to climb over the fence, subsequently being found in the road by an off-duty staff member. On a separate occasion, the same resident again used a chair to climb over the fence and was not noticed missing for three to four hours, eventually being found several miles from the facility. Staff interviews revealed that required face checks and monitoring were not consistently performed, and door alarms did not sound or were not heard during these incidents. The resident involved had a history of elopement from a prior secure facility, diagnoses including schizophrenia and diabetes, and was assessed as cognitively intact on some assessments but with memory and decision-making difficulties noted in others. The care plan identified the resident as at risk for elopement, but interventions such as close monitoring and ensuring re-entry after smoking were not effectively implemented. Staff statements indicated confusion about the resident's whereabouts, lack of awareness of the resident's absence, and failure to respond to or hear door alarms. Additionally, there was a lack of timely notification to law enforcement when the resident could not be located on facility grounds, contrary to facility policy. A second resident, also identified as high risk for elopement, exited the building through a dining room door with a faint alarm and was found by staff in the parking lot. The facility had identified 45 residents as high risk for elopement, and issues were found with two residents. The report documents that the facility's elopement and wandering resident policy was not consistently followed, including the use of alarms, supervision, and timely response to missing residents. These failures resulted in residents leaving the facility unsupervised and unaccounted for, with staff and leadership interviews confirming lapses in monitoring, communication, and adherence to established protocols.