Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of progressive brain disease, paranoid schizophrenia, dementia psychosis, depression, convulsions, and nicotine dependence was not adequately supervised, resulting in an elopement from the facility. The resident, who was assessed as having fair to poor safety awareness and identified as an elopement risk, was able to leave the facility premises without staff knowledge. The resident reported knowing the code to the door leading outside and accessed a key stored in a box on the fence to unlock the gate, leaving the facility while it was still dark outside. Staff interviews revealed that routine checks were supposed to be conducted every two hours, but the resident was last seen in their room at approximately 5:00 AM and was not accounted for during subsequent checks. The absence was only discovered after breakfast was delivered to the resident's room and the resident was not found. The resident was later located by a staff member off facility property and returned to the facility. Review of facility policy indicated that routine checks were required to ensure resident safety, but these were not effectively implemented in this case.