Failure to Supervise and Prevent Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to supervise and ensure the safety of a resident in accordance with its Wandering and Elopement Policy and Procedure. The resident, who had chronic obstructive pulmonary disease, chronic pulmonary edema, and bilateral below-the-knee amputations, was moderately cognitively impaired and required significant assistance with activities of daily living. Despite these needs, the resident was able to leave the facility unsupervised through a parking lot gate after an unknown pedestrian pressed the gate button, which was then opened by the receptionist without verifying the identity or purpose of the individual at the gate. The resident was last seen in the facility's patio area in the afternoon and was not accounted for during routine checks by staff. Multiple staff interviews revealed that the resident was not observed returning to his room at the usual time, and there was uncertainty among staff regarding supervision responsibilities in the patio area. The facility's security camera footage later confirmed that the resident exited the facility through the parking lot gate with the assistance of a pedestrian, and staff did not realize the resident was missing until several hours later during shift change and meal distribution. The receptionist, who was responsible for monitoring the parking lot gate, did not follow the facility's protocol to verify the identity of individuals requesting access. This lapse allowed the resident to leave the premises undetected. The resident was eventually found by a neighbor and admitted to a general acute care hospital with decompensated congestive heart failure and pleural effusion after being exposed to the outside environment for an extended period. The facility's failure to provide adequate supervision and to follow established procedures directly led to the resident's elopement and subsequent hospitalization.