Failure to Provide Adequate Supervision for High Elopement Risk Resident During Outdoor Activity
Penalty
Summary
A deficiency occurred when a resident with a known high risk for elopement was not provided with adequate supervision during an outdoor group activity. The resident, who had a diagnosis of unspecified dementia and a BIMS score indicating moderate cognitive impairment, was assessed as a high elopement risk and wore a wander guard. Despite these precautions, the resident was able to leave the supervised activity area without staff noticing and walked to a nearby family home. The absence of direct supervision was confirmed by multiple staff interviews, with several staff members stating that no CNA was assigned to supervise residents with wander guards outside at the time of the incident. The resident's care plan included specific interventions for elopement risk, such as providing diversions, structured activities, and 1:1 supervision when outside, as well as the use of a wander guard. However, during the outdoor activity, staff were engaged in other tasks such as passing ice cream, providing entertainment, and assisting other residents, which led to a lapse in direct supervision. Staff interviews revealed confusion about who was responsible for supervising residents with wander guards, and it was acknowledged by the DON and other staff that there was a lack of clear assignment for supervision during the event. The resident was ultimately located by family and returned to the facility without injury. Documentation and interviews indicated that the facility's policy required supervision for residents at risk of elopement, but this was not consistently implemented during the incident. The DON and other staff confirmed that the expectation was for nursing staff to supervise residents with wander guards when outside, but this did not occur during the group activity. The deficiency was attributed to a breakdown in communication and assignment of supervision responsibilities, resulting in the resident's unsupervised exit from the facility.