Failure to Prevent Elopement and Ensure Supervision of Exit-Seeking Residents
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for residents with known exit-seeking behaviors, resulting in two separate incidents of elopement. In the first incident, a resident with a history of wandering, cognitive impairment, and a high risk for elopement was able to leave the courtyard through an unlocked gate that had been propped open by contractors. The resident was observed leaving by another resident, and staff were notified and able to redirect the resident back into the building. Prior assessments and care plans had identified the resident's risk for elopement and included interventions such as staff education, regular checks, and redirection, but these measures were not effectively implemented to prevent the resident from exiting the secured area. In the second incident, another resident with a traumatic brain injury, aphasia, depression, and severe cognitive impairment was found missing after a representative inquired about their whereabouts. Staff were unaware the resident was missing until notified, and the resident was found minutes later in the facility's independent living parking lot. The resident had exited the courtyard through a gate, which was observed to have an unlocked key lock, and traversed through unsecured areas leading to the parking lot. Prior documentation indicated the resident had exhibited wandering and exit-seeking behaviors, including attempts to leave the facility and statements about needing to go elsewhere, but the facility did not ensure the courtyard gates were secured or that staff were monitoring the resident closely enough to prevent elopement. Observations during the survey revealed that multiple gates in the courtyard and patio areas were either unlocked or had dummy locks, allowing residents to exit the secured areas without staff intervention. Staff interviews confirmed that they were aware of the residents' exit-seeking behaviors but did not implement one-on-one supervision or other effective interventions until after the elopement incidents occurred. The facility's failure to secure the environment and provide adequate supervision directly contributed to the residents' ability to leave the premises unsupervised.