Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor and supervise a resident with severe cognitive impairment and a known history of exit-seeking behavior. The resident, who had diagnoses including type 2 diabetes mellitus, hypertension, alcohol dependence, depression, muscle weakness, and impaired mobility, was assessed as being at risk for elopement. Despite this, the resident was able to leave the facility on multiple occasions without staff knowledge. Documentation showed that the resident's care plan identified the risk and included interventions such as a wander guard device, increased supervision, and ensuring the resident's bedroom screen door was locked. On several occasions, the resident was found outside the facility or attempting to leave, sometimes without the wander guard in place or with the device removed. Staff interviews revealed inconsistencies in the implementation and documentation of increased supervision and 1:1 monitoring. There was also a lack of clarity and evidence regarding how these interventions were carried out. Orders were in place for frequent monitoring and checking the wander guard, but the resident was still able to exit the facility undetected, and staff did not always hear the wander guard alarm or find the device after incidents. The facility's failure to consistently implement and document the required supervision and monitoring interventions, as well as to ensure the effectiveness of the wander guard system, resulted in repeated incidents where the resident left the premises without staff awareness. This lack of adequate supervision and monitoring directly contributed to the deficiency cited in the report.