Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a newly admitted resident with dementia and anxiety disorder. The resident was admitted for a respite stay and, although initially assessed as not at risk for elopement, began to exhibit confusion, wandering, and exit-seeking behaviors shortly after admission. Staff observed the resident ambulating in hallways, attempting to exit through alarmed doors, and expressing a desire to leave, but the initial elopement risk assessment was not updated to reflect these behaviors. On the evening following admission, the resident eloped from the facility without staff knowledge. Door alarms sounded around the time of the elopement, but staff attributed the alarms to a visitor and to other residents being taken outside for a smoking break. Staff did not check the exterior of the building or conduct a head count when the alarms sounded, resulting in a delay in discovering the resident's absence. The facility was notified of the elopement by a community member who found the resident at a nearby apartment complex, appearing confused. Interviews and record reviews revealed that staff had observed the resident's wandering and exit-seeking behaviors but did not implement increased supervision or update the care plan in a timely manner. The lack of immediate response to door alarms and failure to account for all residents contributed to the resident's unsupervised exit from the facility. The deficiency was identified as having placed the resident at risk for harm, serious injury, or death.