Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards, resulting in a resident with severe cognitive impairment eloping from the facility on two separate occasions within the same day. The resident, who had diagnoses including schizophrenia, anxiety disorder, conversion disorder with seizures, and moderate intellectual disabilities, was assessed as severely cognitively impaired with a BIMS score of 4 out of 15. The resident also had a documented history of wandering and exit-seeking behaviors, and required supervision according to her care assessments. On the day of the incidents, the resident was first observed leaving the facility through a designated door and was later found lying in the middle of a main road outside the premises. Staff initially attempted to locate her after the alarm sounded, but she was not immediately found on the property. After additional staff joined the search, the resident was located and brought back inside, where she continued to attempt to leave. Later the same day, the resident again eloped, triggering alarms, and was found walking in the staff parking lot. Staff intervened and redirected her back into the building, but she exhibited combative behavior during the process. Interviews with staff confirmed that the resident successfully exited the building twice, with supervision lapses occurring during shift changes. Documentation and staff accounts indicated that the resident's risk for elopement was known, and interventions such as room supervision were in place but were not consistently maintained, particularly during critical times such as shift handovers. The facility's failure to ensure continuous and effective supervision directly led to the resident's repeated elopement incidents.