Failure to Supervise and Secure Exit for Elopement Risk Resident
Penalty
Summary
A facility failed to ensure the safety and adequate supervision of a resident with a known risk for elopement and multiple complex medical and psychiatric diagnoses, including paranoid schizophrenia, COPD, hypertension, and epilepsy. The resident had a documented history of exit-seeking behavior, restlessness, agitation, and impaired cognition, and required supervision for activities of daily living and ambulation. Despite these risks, the resident was able to leave the facility through an unlocked and disarmed exit door without staff noticing, as there was no staff present in the hallway at the time and the door alarm had not been activated as required by facility policy and the resident's care plan. The lack of communication among staff and the interdisciplinary care team contributed to the deficiency. The social services director was aware of the resident's prior elopement attempts and exit-seeking behaviors, as reported by the responsible party, but this information was not shared with the care team or nursing staff. As a result, the care plan interventions for elopement risk were not effectively communicated or implemented. Licensed nurses and other staff members were not made aware of the resident's specific risks, and shift huddles intended to communicate such information were not conducted. Staff assigned to the resident did not read or were not informed of the care plan interventions, and did not provide the necessary supervision or monitoring. Additionally, there were no systems in place to ensure that exit door alarms were armed at the required times, and staff were not consistently checking or activating the alarms. Multiple staff members, including licensed nurses and supervisors, did not verify the status of the alarms or ensure that the environment was secure, as required by both facility policy and the resident's care plan. This failure to supervise, communicate, and implement safety measures resulted in the resident eloping from the facility and subsequently being found deceased off the premises.