Failure to Provide Adequate Supervision and Timely Interventions Following Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent an incident of elopement involving a resident with cognitive impairment and poor decision-making skills. The resident, admitted with diagnoses including senile degeneration of the brain, anxiety, and diabetes mellitus type II, was assessed as cognitively impaired and expressed a desire to leave the facility, but the initial wandering risk assessment did not indicate a risk score or clear risk level. On the date of the incident, the resident was found in the facility parking lot heading toward a busy road and was returned to the facility by staff. Prior to the elopement, the resident was known to wander within the facility but had not shown exit-seeking behaviors, and no interventions or increased supervision were implemented immediately following the incident. Review of the medical record and interviews with staff confirmed that there was no documentation of one-to-one monitoring or other safety interventions after the elopement, aside from a general instruction to keep an eye on the resident. The care plan was not updated to include interventions related to elopement or wandering until two days after the incident, and the resident was not transferred to a secure memory care unit until that time. The facility's policy required adequate supervision and individualized care planning for residents at risk of wandering or elopement, but these measures were not implemented in a timely manner for this resident.