Resident Elopement Due to Inadequate Supervision and Exit Security
Penalty
Summary
A deficiency occurred when a resident with significant medical needs, including ventricular tachycardia, hypotension, depression, and the use of a life vest for cardiac risk, eloped from the facility without staff knowledge or supervision. The resident required substantial to maximal assistance with activities of daily living and was known to need continuous monitoring due to his medical condition and the use of a life vest. Despite these needs, the resident was able to exit the facility through the dining room exit doors in a wheelchair, as confirmed by video surveillance footage. Staff interviews revealed that the resident was last seen by a CNA during routine rounds and was later observed attempting to get out of bed and pull out his G-tube. This behavior was reported to nursing staff, but no further interventions were implemented. The CNA and LVN both stated that residents were not permitted to go downstairs unsupervised, and there was no nursing personnel assigned to the first floor to monitor residents in that area. The lack of supervision and unclear responsibility for monitoring residents on the first floor contributed to the resident's ability to leave the facility undetected. The facility's maintenance supervisor confirmed that while the dining room exit doors could be locked from the outside, they could be freely opened from the inside, allowing residents and visitors to exit at any time. The Director of Nursing acknowledged that the resident was unsupervised and away from the facility for approximately five hours. The facility's policy emphasized the importance of resident safety and supervision, but these measures were not effectively implemented, resulting in the resident's elopement.