Failure to Prevent Repeated Elopements Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent repeated elopements for a resident identified as being at risk for wandering and exit-seeking behaviors. Over a nine-month period, the resident exhibited more than 20 instances of exit-seeking or attempted elopement, with five successful elopements, including one incident where the resident was found at a local emergency room after leaving the facility. Documentation showed that the resident had a history of wandering, was assessed as high risk for elopement, and wore a wander guard bracelet since admission. Despite these risk factors and repeated incidents, the care plan interventions remained unchanged and did not include increased supervision or more frequent monitoring. Staff interviews and record reviews revealed that on the day of the most recent elopement, three evening shift staff members failed to ensure that a facility door was properly latched, which allowed the resident to leave undetected for approximately two hours. The facility's elopement policy in place at the time had not been updated since 2013, and interventions in the care plan were limited to distraction techniques and routine checks of the wander guard device, without escalation in response to the resident's ongoing behaviors. There was also a lack of documentation regarding discussions with the resident's family about potential placement in a more secure unit.