Failure to Prevent Resident Elopement and Ensure Adequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, psychotic disturbance, and impaired safety awareness eloped from the facility without staff knowledge. The resident was assessed as having moderate cognitive impairment and required supervision for activities of daily living, but was considered low risk for elopement according to the facility's assessment. The care plan included interventions such as distraction from wandering and offering structured activities, but there were no alarms or wander guards in place, and no physician orders for safety monitoring devices or a secured unit. On the day of the incident, the resident was last seen by staff and other residents at various times in the afternoon, with the last confirmed sighting being when the resident was observed leaving the building through the front exit doors. Staff did not notice the resident was missing until several hours later when medication administration was attempted. A search was initiated inside and outside the facility, and the police and family were notified. The resident was eventually found the next morning by a staff member searching the surrounding area, having walked several miles to a previous address and spending the night in a car in cold weather. Documentation in the resident's medical record was lacking, with no evidence of the resident being observed missing, notifications, or details of the resident's return. The incident was also not recorded in the facility's incident/accident log. Staff interviews revealed inconsistent accounts of the resident's whereabouts and the timing of events, and the facility's policy on elopement required investigation and reporting of missing residents, which was not fully followed in this case.