Failure to Prevent Resident Elopement Due to Lapses in Gate Inspection and Documentation
Penalty
Summary
The facility failed to prevent a resident from eloping by not conducting regular inspections of the exterior gate and by not documenting the resident's wandering behavior as required by the care plan. The resident, who had diagnoses including schizophrenia, type 2 diabetes mellitus, and anemia, was admitted with fluctuating capacity to understand and make decisions. The Minimum Data Assessment indicated the resident had moderately impaired cognitive skills and required supervision for daily activities, but had not previously exhibited wandering behavior. Despite this, the care plan identified the resident as an elopement risk and required documentation of wandering episodes. On the day of the incident, the resident was last seen early in the morning and was later found missing. Interviews revealed that the Director of Maintenance had not kept a documented log of routine inspections for the exterior gate, which was secured with an old padlock and chain. The padlock was found to be disengaged, likely due to force applied by the resident. Additionally, nursing staff did not monitor or document the resident's wandering behavior as outlined in the care plan, and there was no evidence of tracking or reporting these episodes. Facility policies required both regular maintenance inspections and documentation of elopement risks and interventions, but these were not followed, resulting in the resident leaving the facility unsupervised.