Resident Elopement Due to Lapse in 1:1 Supervision
Penalty
Summary
A resident with a long history of mental health issues and houselessness was admitted to the facility and assessed as being at risk for elopement. The resident's care plan included interventions such as regular monitoring, redirection, offering food and fluids, providing activities during wandering or exit-seeking episodes, and 1:1 supervision until exit-seeking behavior resolved. The resident was noted to be cognitively impaired, with poor decision-making skills, and was able to ambulate independently without an assistive device. The resident also refused medications, resulting in hallucinations and an inability to ask for assistance. On the night of the incident, the resident was observed by the front door, with a CNA assigned to monitor them. The CNA was not positioned closely due to the resident's preference for personal space. At some point, the CNA left the resident unattended for a brief period to notify the nurse that the resident was attempting to leave. During this time, the resident exited the facility without staff knowledge. Staff searched the facility and surrounding neighborhood but were unable to locate the resident, and the police were notified. The resident was later found by police several blocks away, sitting on a private residence's porch. Facility staff attempted to persuade the resident to return, but the resident refused and expressed a desire not to return. Interviews with staff confirmed that 1:1 supervision was expected when the resident exhibited exit-seeking behavior, and that the resident was left unsupervised at the door, which allowed the elopement to occur.