Failure to Train Staff on Elopement Policy Leads to Resident Elopement
Penalty
Summary
Nursing staff failed to follow the facility's elopement policy, resulting in a resident leaving the facility unattended. On the day of the incident, a staff member received a call from the police department notifying them that a resident had been found outside the facility near an apartment complex. A head count was then conducted, revealing the resident was missing. The staff member who responded to the door alarm did not hear the alarm and did not perform a head count after checking the perimeter, as required by facility policy. The staff member was unaware that a head count was necessary and had not read the facility's elopement policy, despite having received orientation at the start of employment. Review of facility documentation confirmed that the elopement policy required a head count and a facility-wide response when a door alarm was triggered without an identified cause. The resident's nursing progress notes and the facility's timeline indicated that the resident exited through the front doors and was not noticed by staff during the initial response to the alarm. The lack of staff knowledge and adherence to the elopement policy directly contributed to the resident's ability to elope from the facility.