Failure to Prevent Resident Elopement Due to Inadequate Supervision and Lapses in Security
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident with a history of traumatic brain injury, psychotic disorder, schizophrenia, and bipolar disorder. The resident was assessed as high risk for falls due to psychotropic medication use but was not identified as at risk for elopement. Despite previous incidents where the resident attempted to leave the facility and staff intervention was required, the care plan and elopement evaluation did not reflect these behaviors, and no additional precautions were implemented. On the night of the incident, only one nurse and one CNA were present, and the nurse was unfamiliar with the overnight shift. The resident became agitated due to a lack of cigarettes, repeatedly attempted to leave, and was not successfully redirected by staff. During a period when both staff were occupied with another resident, the resident was left unsupervised and was able to access a key to disable the door alarm, exit through a fenced patio, and leave the premises. The alarm did not sound, and staff were unaware of the resident's departure until she could not be located. Attempts to contact the Administrator and DON were unsuccessful, and law enforcement was eventually notified. The resident was later found in a private home and transported to the hospital. Interviews revealed that staff were unclear about the location and control of keys, the function of the alarm system, and the facility's policy regarding elopement risk and supervision. The resident had a history of accessing restricted areas and items, and staff noted discrepancies in communication and documentation regarding her behaviors. The facility's policy required prompt reporting and intervention for residents attempting to leave, but these procedures were not effectively implemented, contributing to the resident's elopement.