Failure to Prevent Resident Elopement Due to Inadequate Supervision and Lax Key Security
Penalty
Summary
A deficiency occurred when a resident with a history of bipolar disorder and epilepsy, who was assessed as having intact cognition and ambulates independently, left the facility without following the leave of absence (LOA) policy. The resident had previously been identified as at risk for elopement, and the care plan included interventions such as ensuring staff awareness of the resident's wander risk and adherence to the LOA policy. Despite these interventions, the resident was able to access a key left in an accessible location at the staff desk, unlock a rear door, and exit the facility without staff knowledge. The resident traveled by bus to visit a relative at a hospital and later requested police assistance to return to the facility. Staff interviews and record reviews revealed that the LOA log was not completed as required, and the nurse on duty did not sign off on the resident's departure or return. Video surveillance confirmed the resident's actions in obtaining the key and exiting the facility. Staff acknowledged that the key remained accessible in the same location even after the incident, and the resident's unauthorized absence was only discovered when the police contacted the facility. These actions and inactions resulted in a failure to provide adequate supervision and prevent an elopement, as required by facility policy.