Failure to Prevent Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and interventions to prevent elopement for a resident identified as being at risk for wandering and elopement. The resident, who had dementia and was the only ambulatory individual in their household, had an elopement risk evaluation score indicating a high risk for elopement. Despite this, the resident's care plan did not address elopement risk, and there were no documented interventions specific to preventing elopement for this resident. On the day of the incident, the resident exited the facility through a door that was not properly alarmed due to a power surge from recent storms, which caused the door alarm to go offline. The resident was later found by security lying on the sidewalk outside the exit, having sustained a fall and a fracture of the right wrist. Staff interviews confirmed that the resident had been exhibiting exit-seeking behaviors and restlessness prior to the incident, and staff had been checking on the resident more frequently due to these behaviors. Observations revealed that while most exit doors were secured with alarms and egress releases, the door used by the resident was not functioning as intended at the time of the incident. Facility policy required that residents at risk for wandering or elopement have care plans with strategies and interventions to maintain safety, but this was not implemented for the resident in question. The lack of a care plan addressing elopement, combined with the failure of the door alarm system, directly contributed to the resident's unsupervised exit and subsequent injury.