Failure to Prevent Resident Elopement and Injury Due to Inadequate Supervision and Safety Measures
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident was free from preventable accidents, including elopement. The resident, who had multiple diagnoses such as vascular dementia, diabetes, and a history of falls, was identified as high risk for both falls and elopement. Despite care plans indicating the need for interventions such as 1:1 supervision as staffing allows, use of a wander guard, and placement in a high-traffic area, the resident was able to leave the facility unsupervised. Documentation shows that the resident had a history of wandering and delusional behavior, including expressing intentions to go to a casino, and had previously experienced multiple falls. On the day of the incident, the resident exited the facility without staff knowledge and was found by emergency services outside the facility after sustaining a fall, which resulted in injuries including a left knee skin tear and a right arm fracture. Staff interviews revealed that no code yellow (elopement alert) was called because staff were unaware the resident was missing. Several staff members described the resident as confused, delusional, and frequently wandering, with some staff noting that the facility was short-staffed on the day of the incident. Maintenance staff reported that only the front door had a working wander guard, while other doors had generic alarms, and some wander guard systems were not functioning properly. Facility documentation and staff interviews confirmed that the resident's elopement was not immediately detected, and the resident was not reported missing until after being found by emergency responders. The facility's policies required appropriate assessment, interventions, and supervision to prevent accidents related to unsafe wandering or elopement, but these measures were not effectively implemented for this resident. The lack of timely detection and response to the resident's absence, combined with inadequate functioning of safety devices and insufficient supervision, directly contributed to the resident's elopement and subsequent injuries.