Failure to Provide Adequate Supervision and Prevent Resident Elopement
Penalty
Summary
A resident with a history of cognitive impairment, depression, and dementia was involved in two separate incidents where she left the facility grounds without appropriate staff supervision. On one occasion, the resident, who had a BIMS score indicating moderate cognitive impairment, was allowed to participate in an outside activity under the supervision of an activities assistant. During this activity, she informed the assistant that she wanted to see an event on the other side of the facility and subsequently walked out of staff sight. She was later found by another staff member walking around the back of the facility. Her care plan at the time required her to be accompanied by staff or a responsible party when leaving the facility, and she was identified as needing supervision when outside. The incident was reported, and her care plan was updated to reflect her increased risk for elopement. A second incident occurred when the same resident was found at an apartment building across the street from the facility, having left without staff knowledge or supervision. Although she had signed out earlier in the day for a different time, there was no documentation of her leaving the facility at the time of the incident, nor was there any record of exit-seeking behavior or interventions in her medical record. Staff interviews revealed that the resident was not permitted to leave the property unsupervised, and staff were instructed not to report or document the incident. The resident's care plan and outside activity agreements required her to remain on facility property unless accompanied by family or staff, and to notify staff when leaving, but these protocols were not followed or enforced during the incident. Further review showed inconsistencies in the resident's risk assessments and care planning, including a BIMS score that changed significantly after the incident and a lack of documentation regarding her elopement. The facility's policies required documentation and investigation of elopement events, as well as regular evaluation and updating of care plans for residents at risk of wandering or elopement. However, these procedures were not adhered to, and the incident was not reported to the state agency or the resident's representative in a timely manner. Staff and family interviews confirmed that the resident required more supervision than was provided, and that facility protocols for monitoring and documenting her whereabouts were not consistently implemented.