Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of cerebral infarction, unspecified dementia, psychotic and mood disturbances, and anxiety was not provided with adequate supervision to prevent elopement. The resident, who had been assessed as a moderate elopement risk, was able to leave the facility unsupervised by following a transport company staff member who used a staff-only passcode to open the exit door. The resident was found half a block away from the facility with her walker and was brought back by staff. There was no prior documentation of exit-seeking or elopement attempts for this resident in the days leading up to the incident. The incident was discovered when a housekeeper, after leaving the building, observed an elderly individual with a walker in the street and reported it to the administrator. The administrator and housekeeper located the resident and returned her to the facility. Review of video footage showed that the resident exited through the main door as a transport company staff member entered, without being questioned or stopped. The door alarm did not sound because the staff member used the entry code, and no staff were aware of the resident's departure until after the fact. Interviews with facility staff revealed that they had not previously observed exit-seeking behaviors from the resident and were unaware of her elopement until notified. The facility's policies required all staff to monitor exit doors and report any attempts or suspicions of elopement, but in this case, the procedures were not effectively implemented, allowing the resident to leave the premises without detection.