Failure to Provide Adequate Supervision for High-Risk Elopement Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a resident identified as high risk for elopement. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and anxiety disorder, was assessed as having moderate cognitive impairment and required partial to moderate assistance with activities of daily living. The resident had a documented history of elopement attempts and had verbally expressed a desire to leave the facility. Despite these risk factors, the resident was able to remove her wander guard bracelet, which she found uncomfortable, and refused to have it reapplied. The care plan was updated to indicate frequent visual checks, but did not specify the frequency or documentation requirements for these checks. On the day of the incident, the resident was able to leave the facility without staff knowledge by using a chair to exit through a window. She spent the day shopping and returned to the facility without injury, only informing her sister of her whereabouts. Interviews with staff revealed that the care plan's instructions for frequent visual checks were unclear, lacking specific intervals and documentation protocols. Both the LVN and DON acknowledged that the care plan should have been more precise to ensure the resident's safety and adequate supervision. A review of facility policies indicated that individualized care plans should include measurable objectives and timetables, and that resident safety and supervision are facility-wide priorities. However, the lack of specificity in the resident's care plan and the absence of clear monitoring procedures contributed to the failure to prevent the resident's elopement.