Failure to Prevent Elopement and Accident Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with severe cognitive impairment and a known risk for wandering. The resident, an 85-year-old male with diagnoses including unspecified dementia, anxiety disorder, and unspecified convulsions, had a BIMS score of 6, indicating severe cognitive impairment, and was identified as a significant elopement risk. Despite care plan interventions and a physician order for 30-minute monitoring, the resident was left unsupervised in the dining room while staff retrieved other residents. During this period of inadequate supervision, the resident exited the facility through an unlocked dining room door. The door was found to be unlocked at the time, and the facility was unable to determine which staff member had left it unsecured. The resident was discovered outside the facility, lying on the ground near the dining room door, having sustained a fall during the elopement. Upon assessment, the resident showed no signs of injury and reported no pain. Prior to the incident, exit doors were only checked once daily for lock and alarm functionality. Staff interviews confirmed that the resident was left alone in the dining room and that the elopement occurred during this lapse in supervision. The facility's failure to maintain a secure environment and provide adequate supervision directly led to the resident's elopement and fall.