Failure to Prevent Elopement Due to Inadequate Supervision and Door Malfunction
Penalty
Summary
The facility failed to ensure a resident with severe cognitive impairment and a known history of wandering received adequate supervision to prevent elopement. The resident, who had diagnoses including dementia and Alzheimer's disease, was assessed as high risk for elopement. On one occasion, the resident exited the facility by following a vendor out the main entrance when the receptionist unlocked the door, and was found outside across a two-lane street before being returned to the facility. At the time, the resident sustained a minor skin tear and was placed on increased supervision, but this heightened monitoring was discontinued after a few days. Subsequently, the same resident eloped again through the main entrance, which was found to have a malfunctioning locking mechanism that allowed the door to bounce away from the frame and not secure properly. The resident was not immediately accounted for during a head count after the door alarm sounded, and was later found by a staff member at a nearby convenience store. The resident was returned to the facility without injury and placed on one-to-one supervision for the remainder of the stay until transfer to another facility. Interviews and documentation revealed that staff were aware of the resident's elopement risk, and the facility had policies in place requiring systematic monitoring and supervision for residents at risk of elopement. However, the facility did not maintain adequate supervision or ensure the effectiveness of interventions after the initial incident, and failed to identify and correct the door locking issue in a timely manner. These failures resulted in two separate elopement incidents for the same resident, placing the resident and others at risk.