Resident Elopement Due to Inadequate Supervision and Alarm Failure
Penalty
Summary
A deficiency occurred when a resident with a history of cirrhosis, hepatic encephalopathy, restlessness, and agitation eloped from the facility and was missing for over five and a half hours before being found by a passerby nearly nine miles away. The resident had been assessed as having no elopement risk on a prior assessment, despite care plan documentation indicating potential for elopement and exit-seeking behaviors. The care plan included interventions such as frequent monitoring, activities, and room checks, but these measures were not effectively implemented to prevent the resident from leaving the facility undetected. On the night of the incident, the resident was last seen in the early morning hours and was able to exit through the front door by using the electric latch retraction. Camera footage confirmed the resident left the facility independently, dressed in street clothes and outdoor shoes. Staff interviews revealed that routine rounds were conducted every two hours, but the resident was not observed to be exit-seeking by some staff, and the door alarm did not alert staff to the resident's departure. There was confusion among staff regarding the functionality of the alarm system, with some reporting that the alarm was sensitive and would typically sound, while others noted that it did not activate on the night in question. The facility's documentation and interviews indicated that the alarm system was supposed to be engaged during nighttime hours and required a code to disarm. However, it was unclear how the resident was able to exit without triggering the alarm, and staff could not determine whether the alarm malfunctioned or if the resident had obtained the code. The lack of effective supervision and failure to ensure the alarm system functioned as intended directly contributed to the resident's ability to leave the facility without detection.