Failure to Provide Adequate Supervision Resulting in Resident Elopement and Self-Harm
Penalty
Summary
A deficiency occurred when facility staff failed to provide adequate supervision for a resident assessed as needing 24-hour supervision for safety due to a history of suicidal ideation, aggression, and behavioral health diagnoses. The resident, who had diagnoses including schizoaffective disorder, personality disorder, impulse disorder, major depressive disorder, and anxiety, was independently ambulatory and had a care plan indicating a need for close monitoring due to risks of self-harm and aggression. Despite these documented needs, staff did not follow the facility's rounding policy, which required hourly checks and physically seeing each resident in their rooms. On the night of the incident, the resident exited the secured behavioral unit through a window without staff knowledge and was missing for approximately 12 hours. Staff statements indicated that rounds were documented at various times, but none of the staff physically entered the resident's room to visually confirm their presence after the last observed time at the 8:00 P.M. smoke break. The resident was later found by police at a local store, having spent the night outside and attempted suicide using a piece of glass found at the location. Interviews and record reviews confirmed that staff did not adhere to the facility's policy for making rounds and direct observations, resulting in the resident's undetected elopement and subsequent self-harm. The failure to provide the required supervision and to follow established safety protocols directly led to the resident's ability to leave the facility and attempt suicide while unsupervised.