Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as high risk for wandering, resulting in an elopement event. Upon admission, the resident was assessed as not at risk for elopement, but subsequent documentation showed wandering, exit-seeking behaviors, and impaired safety awareness. Despite these behaviors, the resident was able to exit the facility unsupervised through the front entrance, which was found ajar and off its hinges, with the elopement protection device (EPD) alarm sounding only in the lobby area. Staff did not hear the alarm from the nursing unit, and the resident was last seen in her room before being found outside in the parking lot by an LPN. The resident had a history of dementia, atrial fibrillation, and previous falls, and was noted in progress notes to wander aimlessly, enter other residents' rooms, and exhibit delusions. The care plan and physician orders indicated the use of an EPD and daily checks, but these interventions did not prevent the resident from leaving the building. Staff interviews and documentation revealed that the resident was able to force open the front doors, which, while equipped with an EPD system, could be pushed open due to their fire door function. The alarm system was not audible throughout the facility, limiting staff's ability to respond promptly. The deficiency was confirmed by the Nursing Home Administrator and DON, who acknowledged that the lack of adequate supervision and ineffective alarm coverage led to the resident's elopement. The incident was classified as immediate jeopardy due to the failure to ensure the safety of a resident at high risk for wandering, as required by facility policy and state regulations.