Failure to Prevent Elopement and Provide Adequate Supervision for New Admission
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent an elopement for a newly admitted resident with dementia, Alzheimer's disease, and a history of traumatic brain injury. Upon admission, the resident informed an LPN that he was not staying at the facility, but the LPN did not notify appropriate staff or implement immediate interventions to address the resident's expressed intent to leave. After the resident's family left, the resident followed them outside and was redirected back into the facility by the admissions coordinator, who then briefly supervised the resident in the lobby before leaving. When the admissions coordinator returned, the resident was missing. The facility's investigation revealed that the resident was admitted to an unsecured unit and no enhanced oversight or safety interventions were put in place, as staff believed the resident exhibited no behaviors indicating elopement risk and had no known history of elopement. However, the resident's statement about not staying and his attempt to follow his family outside were not acted upon according to facility policy and protocols. The admissions coordinator also failed to notify staff about the resident's attempt to leave and did not ensure continued supervision. The resident was later found by bystanders at a nearby gas station after having fallen, sustaining abrasions, a laceration, and a fracture to his right hand. Emergency medical services transported the resident to the hospital, and he did not return to the facility. Staff interviews indicated a lack of awareness and inconsistent application of the facility's elopement prevention protocols, including the use of wander guards and notification procedures for residents at risk of elopement.