Failure to Prevent Resident Elopement and Ensure Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for a resident with diagnoses including PTSD and bipolar disorder. The resident exhibited confusion, expressed intentions to leave, and was observed packing belongings in anticipation of being picked up. Despite being fitted with a Wander Guard device, the resident was able to exit the building on two occasions. On one occasion, the resident left in a manual wheelchair and was observed by the receptionist, who summoned staff to assist. The Wander Guard did not alarm as expected, and staff reported that the device was replaced on the resident's wheelchair. On another occasion, the resident was found in the parking lot near the main entrance by an activities staff member, who was unable to persuade the resident to return inside and required assistance from supervisors. Interviews with the DON and a registered nurse confirmed that the resident had a recent change in condition, was difficult to redirect, and had learned the code to exit the building, allowing them to leave without staff knowledge. The facility's policy defined elopement as any situation in which a patient leaves the premises without the facility's knowledge and supervision. Documentation and staff interviews confirmed that the resident was outside the building without staff awareness, indicating a failure to ensure adequate supervision and prevent accident hazards as required by facility policy and state regulations.