Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident from leaving the premises without staff knowledge. A resident with a thoracic spinal cord injury and paraplegia, who was alert, oriented, and independent in activities of daily living using a wheelchair, left the facility on his own at approximately 11:30 p.m. Staff were unaware of the resident's departure and only became aware when the resident returned to the building. The resident reported that he went to a gas station two blocks away and returned on his own, stating that staff did not find him. Facility documentation and interviews revealed that the resident was not aware of the facility's policy regarding leaving the premises. The facility's elopement policy requires staff to promptly report and attempt to prevent residents from leaving, as well as to investigate and report all cases of missing residents. In this incident, staff did not detect the resident's absence in real time, and the resident was not educated on the policy prior to the event, contributing to the failure to prevent the elopement.