Failure to Supervise Smoking Break Leads to Resident Elopement
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate supervision to a resident during a designated smoking break, resulting in the resident eloping from the facility. The resident involved had a complex medical history, including alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, paranoid schizophrenia, bipolar disorder, delusional disorder, mild cognitive impairment, impulsive disorder, intermittent explosive disorder, cocaine abuse, and severe dementia with behavioral disturbances. The resident was identified as an elopement risk and had a care plan in place that required supervision during smoking times and placement in a secured unit. On the day of the incident, staff responsible for supervising the smoking break allowed residents to go outside to smoke but did not remain with them, instead observing from a window due to rain. During this time, the resident at risk for elopement managed to leave the secured courtyard by kicking the gate and exited the premises. The absence of direct supervision enabled the resident to leave the facility undetected for several minutes until discovered in the parking lot by another staff member who was leaving for the day. The resident was safely returned to the facility without injury. Interviews and witness statements confirmed that the staff assigned to supervise the smoking break were not physically present outside with the residents, contrary to facility policy requiring supervised smoking. The Director of Nursing verified that the root cause of the elopement was the lack of appropriate supervision during the smoke break, which allowed the resident to elope from the secured area. Facility records and policies reviewed indicated that the resident's risk for elopement was well-documented, and interventions for supervision were clearly outlined but not followed at the time of the incident.