Failure to Prevent Resident Elopement Due to Inadequate Supervision and Environmental Safeguards
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents, specifically failing to prevent the elopement of a resident identified as high risk for wandering. The resident, a man with multiple diagnoses including dementia, epilepsy, hemiplegia, and a history of elopement risk, was able to leave the facility undetected by climbing out of a window in an unoccupied room. The resident's care plan noted his risk for elopement and included interventions to identify wandering patterns and intervene as appropriate, but these interventions were not effectively implemented. The resident had previously expressed a desire to leave and had demonstrated agitation and exit-seeking behavior, yet staff did not put additional elopement interventions in place prior to the incident. On the day of the incident, the resident was last seen after a smoke break and was later found missing during routine rounds. Staff discovered the resident's wheelchair in front of a window in an adjoining unoccupied room, with the window closed and the screen removed. The resident was found outside, two houses away from the facility, and reported that he had climbed out the window to go to a family member's house. Staff were unaware of the resident's absence until they attempted to deliver his dinner tray, and the facility did not immediately notify law enforcement, as the resident was missing for only a short period. Interviews revealed that staff had not been in-serviced on elopement procedures following the incident, and the administrator was not fully aware of the details of residents' elopement risk assessments. Further observations identified that several windows in the facility were missing screens, and the maintenance director was unsure if replacements had been ordered. The facility's policies required care plans for residents at risk of elopement and outlined emergency procedures for missing residents, including notification of law enforcement, but these were not followed. The lack of effective supervision, failure to implement care plan interventions, and inadequate physical safeguards such as window screens contributed to the resident's ability to elope undetected, resulting in an Immediate Jeopardy situation.