Failure to Prevent Elopement and Inadequate Supervision of At-Risk Residents
Penalty
Summary
The facility failed to ensure that residents at risk for elopement received adequate supervision and that the environment was free from accident hazards, as evidenced by two separate incidents involving residents with documented elopement risks. In the first case, a resident with diagnoses including anxiety disorder, cerebral infarction, and schizoaffective disorder, and with a history of wandering and elopement attempts, was placed on one-to-one supervision. Despite this, the assigned Patient Care Assistant left the resident unattended to take a dinner break without arranging for coverage, and the resident was able to exit the facility undetected. The facility's wander guard system did not alarm, and the resident was later found at a nearby bus station. Staff interviews confirmed that the resident was known to be at high risk for elopement and that one-to-one supervision required the staff member to remain within arm's reach at all times, which was not followed in this instance. In the second case, another resident with diagnoses including dementia with mood disturbance, agitation, and Parkinson's disease, and with severely impaired cognition and wandering behaviors, also eloped from the facility on two separate occasions. The resident was assessed as an elopement risk and had a wander guard in place. After the first elopement, interventions such as 30-minute visual checks and one-to-one supervision at night were ordered, but there was no documented evidence that these interventions were implemented. The resident subsequently eloped again, exiting through the front entrance without staff detection, and was found by police walking on a nearby street. Staff interviews revealed that the wander guard system did not alarm or secure the elevators or exit doors at the time, and there was a lack of internal cameras to monitor resident movement. Throughout both incidents, facility staff, including the DON and Administrator, acknowledged that the required supervision protocols were not followed and that the wander guard system was not fully integrated with all exits and elevators. Staff responsible for one-to-one supervision left residents unattended without arranging for relief, and there was a lack of documentation to show that required safety interventions were consistently implemented. The facility's policies on elopement prevention and one-to-one supervision were not adhered to, directly contributing to the residents' ability to leave the premises unsupervised.