Elopement Due to Inadequate Supervision of High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of wandering, and exit-seeking behaviors was not provided with adequate supervision to prevent elopement. The resident, diagnosed with severe unspecified dementia, schizophrenia, and delusional disorders, had a BIMS score of 00, indicating severe cognitive impairment. The care plan identified the resident as high risk for elopement, with interventions including 15-minute location checks and various diversions. Despite these interventions, the resident was able to break a window and leave the facility undetected. On the day of the incident, the resident was last observed in her room at 7:30 AM. At 7:45 AM, a CNA discovered the resident missing and the window broken when attempting to summon her for breakfast. Staff immediately initiated a search of the unit and grounds, confirmed all other exits were secure, and notified the police when the resident could not be located. The resident was found by police approximately five minutes away from the facility and was exhibiting psychotic behaviors, including hallucinations and delusions, at the time of recovery. Interviews and record reviews confirmed that the resident had previously been on 1:1 supervision, which was later reduced to 15-minute checks due to observed behaviors such as pacing and wandering into other residents' rooms. Staff reported that the required 15-minute checks were being completed, but the resident was able to elope between checks. The incident resulted in the resident being transported to the hospital for evaluation, and the event was classified as Immediate Jeopardy due to the risk of harm and/or serious injury.