Resident Elopement Due to Inadequate Supervision During Smoking Break
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, schizophrenia, anemia, and hypertension was left unsupervised in an unsecured outdoor area during a smoking break. The resident required partial to moderate assistance with activities of daily living and had no prior history of wandering or elopement. Despite the facility's policy requiring supervision of residents at risk for elopement, the resident was able to leave the premises without staff awareness or authorization. On the evening of the incident, staff members, including a Certified Medication Technician (CMT), a Licensed Practical Nurse (LPN), a receptionist, and a Certified Nurse Aide (CNA), were involved in the resident's care and supervision. The resident was last seen participating in activities and waiting for a smoke break. The resident was given a cigarette by the receptionist and went outside to smoke with other residents and a CNA. After approximately 30 minutes, the CNA and other residents returned inside, but the resident did not. Staff did not immediately notice the resident's absence, and subsequent attempts to locate the resident were unsuccessful. The resident's absence was discovered when the CMT attempted to administer medication and could not find the resident. A search was initiated, and the facility followed its elopement protocol, including notifying the family and police. The resident was found the following morning by activity staff, having spent the night outside. The resident reported feeling "caged" and left the facility during the unsupervised smoking break. The resident sustained a minor burn on the forearm, which was self-reported as unrelated to the incident. The deficiency was due to the failure to provide adequate supervision and oversight, allowing the resident to elope from the facility.