Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and did not provide adequate supervision to prevent elopement for three residents. In one instance, a resident with schizoaffective disorder, a history of wandering, and moderately impaired cognition exited the facility unsupervised through an alarmed rear exit patio door. The alarm was triggered, but the security officer did not respond, and the resident was not located until they arrived at the hospital emergency department. The resident had previously refused to wear a wander guard, and staff did not notice the resident's absence during routine activities such as dinner service. Another resident with schizophrenia, alcohol abuse, and moderately impaired cognition left the facility unsupervised and was later found at a friend's house. The resident was not identified as missing until after the last staff observation, and it was determined that the resident likely exited through the front door, which was not alarmed at the time. The security desk's location partially obstructed the view of the lobby, and the security officer did not ensure that all individuals leaving the facility signed out, as required by policy. A third resident with dementia and moderately impaired cognition was last seen interacting with peers and was later found missing during dinner service. The resident was not previously assessed as being at risk for elopement and did not have a wander guard in place. The resident was located by police the following day and returned to the facility. Family members expressed concern about the lack of supervision and questioned why a resident with dementia did not have additional safety measures in place. Staff interviews revealed inconsistent practices regarding monitoring, safety checks, and the use of elopement prevention tools.