Failure to Prevent Resident Elopement Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement risk and severe cognitive impairment was not adequately supervised, resulting in two separate elopement incidents. The resident, who had diagnoses including anoxic brain damage, unspecified convulsions, diabetes mellitus, asthma, hypothyroidism, restless leg syndrome, and dysphagia, was assessed as high risk for wandering and elopement. Physician orders and care plans specified the use of a wander guard device, frequent monitoring, and supervision, especially during exit-seeking behaviors. Despite these interventions, the resident was able to leave the facility unsupervised on two occasions. On one occasion, the resident exited through a gate that was left slightly open by visitors who had attended a church service at the facility. The gate, which required a code to enter, was not properly secured after the visitors left. The resident was found by local police wandering on a street near the facility and was transported to a hospital for evaluation. Staff interviews and documentation revealed that the wander guard alarm system was in place, but staff did not check the entire courtyard when the alarm sounded, and the gate was not secured as required. In another incident, the resident was able to leave the facility through the side gate of the courtyard. At the time, the wander guard was attached to the resident's wheelchair rather than his person, as he had previously removed the device from his leg. Documentation indicated that the resident was exit-seeking, and staff were aware of his behaviors, but the supervision and monitoring in place were insufficient to prevent his elopement. These lapses in supervision and failure to secure exit points directly contributed to the resident's ability to leave the facility unsupervised.