Failure to Prevent Elopement Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, identified as an elopement risk with a history of schizoaffective disorder, suicidal ideation, substance abuse, and cognitive impairment, was not adequately supervised, resulting in an elopement event. The resident had previously expressed a desire to leave the facility and made explicit threats to jump out of a window if not allowed to leave. Staff responded by placing the resident on one-on-one supervision and sending him to the hospital for evaluation of suicidal ideation. Upon return from the hospital, documentation indicated the resident did not have suicidal ideation but continued to express a strong desire to leave the facility. Despite the resident's ongoing exit-seeking behaviors and recent threats, one-on-one supervision was discontinued after a period of observed calmness. The care plan did not include specific interventions related to placement on a secured unit for increased elopement risk, and there was a lack of clear communication among staff regarding the resident's supervision status. On the morning following the removal of one-on-one supervision, the resident was able to remove a windowpane from his room and exit the building undetected by staff, ultimately falling two stories to the pavement below and sustaining serious injuries. Interviews and record reviews revealed that staff were aware of the resident's history and behaviors, including his repeated requests to leave, agitation, and threats of self-harm. However, the facility failed to maintain adequate supervision and did not implement or communicate effective interventions to prevent the resident's elopement, despite clear indications of risk. The incident resulted in significant physical harm to the resident and was determined to be a result of insufficient supervision and failure to address known hazards.