Failure to Prevent Elopement of At-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent an elopement for a resident identified as being at risk for wandering and elopement. The resident had a history of intellectual disabilities, paranoid schizophrenia, anxiety, and difficulty walking. The resident's care plan documented impaired safety awareness and a pattern of sitting by exit doors, with interventions to identify and address wandering. Despite these risk factors, the resident was not wearing an electronic monitoring device at the time of the incident, as he had not previously attempted to leave the facility. On the day of the incident, staff observed the resident exhibiting increased restlessness and exit-seeking behavior, including packing belongings and expressing a desire to leave. The resident was last seen eating lunch in the dining room, after which staff noticed he was missing. A search of the facility was conducted, and when the resident could not be located, the police and the resident's power of attorney were notified. The resident was later found safe at a family member's house, having left the facility on his own without staff knowledge or intervention. Interviews with staff and family confirmed that the resident had never previously attempted to elope, although he had a pattern of preparing to leave and waiting for family. Staff reported that the wander guard system was operational, but the resident was not wearing a device. The incident revealed that the facility's supervision and monitoring were insufficient to prevent the resident's unsupervised exit, despite documented risk factors and recent changes in the resident's behavior.