Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement for one resident identified as at risk for wandering and elopement. The resident, who had diagnoses including hypertension, hyperlipidemia, and severe cognitive impairment, was admitted with a history of decreased awareness and required frequent redirection. Despite multiple nursing notes documenting wandering behavior, confusion, and attempts to leave the facility, the initial elopement risk assessment did not identify the resident as at risk. The resident was observed leaving the facility on two separate occasions, once through the front door and another time walking down the highway, both times without appropriate staff intervention or supervision. Staff interviews confirmed that the resident had demonstrated confusion and exit-seeking behaviors since admission, and that interventions to prevent elopement were not implemented in a timely manner. The DON and LPN both acknowledged that the resident should have been considered an elopement risk upon admission and that supervision and preventive measures were lacking prior to the incidents. Video surveillance further revealed that the resident was able to exit the facility by following others without being stopped, indicating a failure to ensure a safe and secure environment as outlined in the facility's own policy.