Failure to Prevent Resident Elopement Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
The facility failed to implement effective interventions to prevent resident elopement for one resident with a known history of exit-seeking behaviors. Clinical records documented multiple instances where the resident was observed attempting to leave the unit, activating the wander guard alarm, and being found near facility exits or on the elevator. Despite these repeated behaviors, the interventions in place, such as the wander guard system and periodic checks, were insufficient to prevent the resident from leaving the building. On one occasion, the resident successfully eloped by walking out the front door and was found outside near a highway before being redirected back into the facility by staff. The wander guard system did sound alarms when the resident approached restricted areas, but it was not integrated with the doors or elevators to physically prevent exit. The front doors were only locked during nighttime hours, leaving them accessible during the day, and there was no staff present at the front desk during the surveyor's visit, allowing for unmonitored exit from the facility. Interviews with the Nursing Home Administrator confirmed that the wander guard system only triggered alarms and did not lock doors or elevators, and that residents could exit the building if staff did not respond to alarms in a timely manner. The lack of effective supervision and environmental controls contributed to the resident's ability to elope, demonstrating a failure to ensure the area was free from accident hazards and to provide adequate supervision to prevent accidents.