Failure to Prevent Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary supervision and prevent an elopement for a resident identified as being at risk for elopement. The resident, who had diagnoses including Parkinson's Disease, cognitive impairment, and other significant medical conditions, was admitted to the secured unit due to her risk status. Despite being care planned for elopement risk and having interventions such as placement in a locked unit, the resident was able to exit the facility undetected. On the day of the incident, the resident left the secured unit and exited through the main entrance while the receptionist was distracted by visitors, and no other staff were present at the entrance. The exit door required manual unlocking after a buzzer was engaged, and the receptionist did not notice the resident leaving, as confirmed by surveillance footage. The facility's layout allowed access from the secured unit to the main lobby and entrance through unsecured hallways. Interviews revealed that, prior to the incident, visitors could enter the secured unit without a code but needed a code to exit, and staff did not typically provide codes to visitors. On the day of the incident, a birthday party for another resident in the main dining room resulted in increased visitor traffic, and it was believed that a visitor may have inadvertently allowed the resident to leave the secured unit. Staff did not observe any exit-seeking behaviors from the resident on the day of the incident, and the resident was last seen in the unit's dining room before being discovered missing during a medication pass and dinner. The resident was found by law enforcement several hours later, approximately two miles from the facility, with minor injuries such as abrasions and bruising. She missed multiple scheduled medication doses during her absence. The facility's policy defined elopement as a resident leaving the premises without authorization or necessary supervision, and the resident's care plan specifically identified her as an elopement risk. Despite these measures, the facility failed to ensure effective supervision and security measures to prevent the resident's undetected exit from both the secured unit and the building.