Failure to Prevent Elopement of High-Risk Residents Due to Inadequate Supervision and Lapses in Security Procedures
Penalty
Summary
Two residents, both assessed as high risk for elopement due to cognitive impairments such as dementia and schizophrenia, were able to leave the facility unsupervised and without staff awareness. Both residents had documented care plans indicating their risk for wandering and required supervision, including monitoring their location every two hours and implementing diversional interventions. Despite these documented needs, staff failed to adequately monitor the residents' whereabouts, and their absence went unnoticed for an extended period. On the day of the incident, a staff member (CNA) observed two women near a locked door leading to the facility's lobby and, believing them to be visitors, signaled for the receptionist to unlock the door. The receptionist, unfamiliar with the residents and not recognizing them as such, allowed them to enter the lobby and subsequently exit through the facility's front entrance. There was no process in place to verify the identity of individuals leaving the facility, and the receptionist did not check for visitor badges or confirm their status before permitting exit. Other staff members later noticed the residents' lunch trays were untouched but did not immediately investigate their whereabouts, assuming they were elsewhere in the facility. The residents were missing for approximately 27 hours before being located by a family member about 20 miles from the facility. Both were subsequently transported to a hospital for evaluation and treatment, with one admitted for altered mental status and the other for a urinary tract infection. Interviews with staff revealed a lack of familiarity with residents, absence of a visitor check-out process, and failure to follow care plan interventions for monitoring high-risk residents, all of which contributed to the residents' unsupervised exit and delayed discovery.