Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent a resident from eloping. The resident, who had a history of impaired safety awareness and a previous elopement, was assessed as low risk for elopement on a recent risk scale. Despite this, the resident was able to leave the facility through a back kitchen door without staff knowledge and was later found by local police in a commercial parking lot approximately 400 feet from the facility. The resident was returned to the facility within 30 minutes, and no injuries were identified upon assessment. The facility's elopement risk guidelines required an assessment for all admissions, readmissions, elopements, and significant changes, with care plans to be initiated for those at risk. The resident's care plan had been updated to reflect their elopement risk, but the incident revealed a lapse in supervision and monitoring, as the resident was able to exit through a door that was not adequately secured at the time. Staff were unaware of the resident's departure until notified by a neighbor and the police.