Failure to Prevent Resident Elopement Due to Inadequate Supervision and Documentation
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents, resulting in a resident leaving the premises without staff knowledge or authorization. The resident, who was under guardianship and had diagnoses including mild cognitive impairment and a history of wandering and elopement, was permitted by their guardian to leave the facility to smoke, as the facility is smoke-free. Despite this, the resident's care plan required staff supervision due to confusion and altered mental status. On the day of the incident, the resident independently arranged for transport and left the facility to attend an appointment that had been previously canceled by the guardian, without signing out or informing staff. The facility's investigation into the incident was incomplete, as there was no documentation of resident or staff interviews, and no evidence that the resident had been signing out when leaving the premises. Staff members, including CNAs, reported not receiving education on elopement procedures following the incident, and the DON was unable to provide documentation of interventions implemented to prevent recurrence. The facility's policy required adequate supervision for residents at risk of elopement, but this was not followed in the case of this resident.