Failure to Prevent Elopement Due to Inadequate Supervision and Staff Training
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who had been identified as an elopement risk. The resident, with a history of metabolic encephalopathy, dementia, impaired safety awareness, and other medical and psychiatric conditions, was care planned as an elopement risk and required a wander guard and supervision when leaving the facility. Despite these interventions, the resident was able to sign himself out at the front desk and exit the facility unattended, after removing his wander guard. The receptionist, unaware of the resident's elopement risk and the proper Leave of Absence (LOA) process, allowed the resident to leave after he signed the book, without verifying with nursing staff or ensuring an escort was present. Interviews revealed that both the Human Resource Coordinator (HRC) and the receptionist were not familiar with the facility's LOA process or the specific protocols for residents at risk for elopement. The receptionist had not received training on the LOA process or participated in any drills related to elopement prevention. The HRC assumed the receptionist knew the process and did not intervene when the resident requested to go outside. The resident was later found across the street, having left the facility without his wheelchair or supervision, and was assisted back by staff and a neighbor. Further review indicated that required elopement assessments were not completed according to facility policy, and documentation of elopement drills prior to the incident could not be produced. The facility's policies required that residents at risk for elopement have individualized interventions, regular assessments, and that staff be trained on LOA procedures. These protocols were not followed, resulting in the resident's unsupervised exit from the facility.