Failure to Provide Adequate Supervision Results in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement and severe cognitive impairment was not provided with adequate supervision, resulting in the resident leaving the facility undetected. The resident had diagnoses including paranoid schizophrenia, epilepsy, panic disorder, anxiety, and depression, and was assessed as being at risk for elopement. The care plan indicated the use of a WanderGuard device and noted the resident's frequent exit-seeking behaviors and moderate fall risk. Despite these interventions, the resident was able to exit the facility through a door equipped with an alarm. On the night of the incident, staff were providing care in residents' rooms and did not hear the door alarm when it was triggered. Multiple staff members confirmed during interviews that the door and WanderGuard alarms were difficult or impossible to hear while inside resident rooms with the doors closed. The alarm was not responded to until several minutes after the resident had already left the facility. The resident was eventually found approximately two miles away, having traversed busy streets and intersections, and was returned to the facility. The facility's policy required staff to be vigilant and respond to alarms in a timely manner, emphasizing that alarms are not a substitute for necessary supervision. However, staff were unaware that the alarm system could not be heard in certain areas, and there was no process in place to ensure alarms were audible throughout the building. Documentation also showed gaps in required 15-minute checks for the resident after the incident. The failure to provide adequate supervision and to respond promptly to the alarm led to the resident's elopement and constituted a finding of immediate jeopardy.