Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, schizoaffective disorder, and other psychiatric diagnoses eloped from the facility without staff knowledge, resulting in actual harm. The resident, who was assessed as a moderate elopement risk and a high fall risk, was able to leave the building during the night shift when staff coverage was inadequate. The care plan for the resident included interventions for fall risk but did not address elopement risk, despite multiple assessments identifying this risk. On the night of the incident, staffing assignments left the resident's hallway unattended when a CNA went to relieve another CNA for a break, and the assigned LPN and another CNA left the premises without authorization. During this period, the resident exited the facility through an employee entrance, triggering a door alarm. The alarm sounded for approximately five minutes without response, as the only staff member present in the area could not leave her post, and another staff member who heard the alarm was not on duty and did not respond. The resident was found outside in the parking lot, inadequately dressed for the weather, after having fallen and sustained a nondisplaced nasal fracture and a right humerus fracture. Interviews with staff confirmed that the hallway was left without supervision, and the resident was not monitored as required. The facility's policies required routine resident checks every two hours and prohibited staff from leaving the property during breaks without supervisor permission. However, these policies were not followed, and the lack of supervision directly contributed to the resident's elopement and subsequent injury.