Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving one resident. According to the facility's Elopement Prevention Guidelines, all residents are to be assessed for elopement risk upon admission, quarterly, annually, and as needed, with regular monitoring of their whereabouts at mealtimes, medication administration, and every two hours during nursing rounds. In this case, the resident's elopement risk assessment did not identify her as at risk, and staff did not observe any behaviors indicating intent to leave. However, the resident was able to leave the facility undetected, as confirmed by security camera footage, and was not noticed missing until the evening meal, approximately four hours after her departure. The resident, who had diagnoses including high blood pressure, dysphagia, and malnutrition, was last seen at lunch and was not found during the dinner meal. Staff initiated the elopement protocol after discovering her absence, searching the building and surrounding areas, and notifying the administrator, police, and the resident's family. The resident was eventually located downtown by a laundry worker, who assisted her in returning to the facility. Upon her return, the resident was assessed and found to have no injuries, and she refused to go to the emergency room for further evaluation. Interviews with staff confirmed that the resident had been gone for approximately seven hours before her safe return, and that there were no prior indications she intended to leave. The Nursing Home Administrator acknowledged that the facility failed to ensure adequate supervision, resulting in the resident's elopement. The deficiency was cited under relevant state codes for responsibility of the licensee, management, and nursing services.