Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and assistance devices to prevent accidents, specifically failing to prevent an elopement by a resident with severe cognitive impairment. The resident, a male with unspecified dementia and no behavioral disturbances noted on his MDS, was admitted for respite care and was independent with mobility. Documentation revealed gaps in the resident's baseline care plan, with several sections left blank, including those related to mood, behavior, and care planning. There was no physician order for monitoring the resident, and the admission documentation did not indicate any assessment or plan for wandering risk. On the day of the incident, the resident was observed to have increased wandering behavior. Staff interviews and record reviews confirmed that the resident was able to leave the facility undetected and was found outside near an access road by the expressway. The front door was observed to be unlocked and unattended at the time, and although staff stated that door alarms were in place, the monitoring of the front entrance was inconsistent. Multiple staff members recalled the event, noting that the receptionist was sometimes away from the desk, and that the resident was able to exit quickly. There was no incident report completed regarding the resident's wandering or elopement, and the family was notified of the attempt to leave by the hospice company, not the facility. Facility policies required identification and supervision of residents at risk for unsafe wandering, as well as completion of incident reports and notification of appropriate parties in the event of an elopement. However, these procedures were not followed in this case. The lack of a completed care plan, insufficient monitoring of exit doors, and failure to document and report the incident contributed to the deficiency. Staff interviews revealed inconsistent understanding and implementation of monitoring responsibilities, and the facility did not have effective measures in place to prevent the resident's elopement.