Failure to Provide Adequate Supervision and Implement Elopement Precautions
Penalty
Summary
A cognitively impaired male resident with a history of Alzheimer's Disease, restlessness, agitation, and a previous elopement attempt was identified as being at high risk for elopement. The resident's care plan included interventions such as a wander guard and 15-minute visual checks, which were to be implemented due to his severe cognitive impairment and prior behaviors. On the evening in question, the resident's family member notified facility staff that the resident had expressed intent to escape through his window. Despite this warning, staff did not immediately assess the resident or his window, nor did they increase supervision beyond the prescribed 15-minute checks. Video surveillance and staff interviews revealed that staff failed to perform the required 15-minute checks as directed by the care plan. No staff were observed entering the resident's room to check on him during the critical period before his elopement. Staff members admitted to not physically checking on the resident every 15 minutes and were unaware of the specific reasons for the increased monitoring. Additionally, staff did not assess the window for potential hazards after being informed of the resident's intentions, and some staff were not trained on how to access or interpret care plans for residents at risk of elopement. As a result of these failures, the resident was able to manipulate the window lock over time and exit the facility through his room window without staff knowledge or supervision. He was later found by staff and police a block away from the facility, near active railroad tracks. The lack of immediate and adequate supervision, failure to follow the care plan, and insufficient staff training directly led to the resident's unsupervised exit and the resulting Immediate Jeopardy finding.