Failure to Prevent Repeated Elopements Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent repeated elopements for a resident identified as being at risk. Record review showed that the resident had a history of exit-seeking behavior, with documentation of at least 20 incidents of attempting to leave the facility and five successful elopements over a period of several months. Despite being assessed as at risk for elopement and having a wander guard bracelet in place, the resident was able to leave the facility when staff failed to ensure a door was properly latched. The resident was later found at a local emergency room after being missing for approximately two hours. The care plan for the resident included interventions such as involving the resident in activities, providing diversions, and ensuring the wander guard bracelet was worn and checked, but these measures were not sufficient to prevent repeated elopement attempts. Staff interviews revealed that discussions about moving the resident to a locked unit were not documented, and the DON acknowledged that more frequent monitoring, such as one-on-one supervision or 15-minute checks, was not implemented. The facility's elopement policy in place at the time had not been updated since 2013.