Failure to Prevent Resident Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to provide necessary care and services to prevent accident hazards for a resident with severe cognitive impairment, resulting in an elopement incident. The resident, who had a documented history of wandering and attempting to enter other residents' rooms, was not assessed for elopement risk following a change in condition. Despite facility policy requiring elopement risk assessments and timely staff response to alarms, there was no documented evidence that the required assessment was completed after the resident exhibited wandering behavior. On the day of the incident, the resident was able to leave the facility in a wheelchair without staff noticing, and the door alarm was not responded to promptly by staff members present. Interviews with staff revealed that the CNA did not hear the door alarm due to being busy, and another staff member, who heard the alarm during a lunch break, did not investigate, assuming someone else would respond. The lapse in supervision and failure to follow established protocols allowed the resident to exit the facility unsupervised. The resident was later found by police outside the facility. Facility leadership acknowledged that the elopement risk assessment should have been completed and that staff should have responded immediately to the door alarm.