Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident was found outside the facility in the parking lot of a neighboring apartment complex at approximately 10:00 p.m. The resident was not in her room at 9:30 p.m., prompting a search of the building, and was located outside around 9:45 p.m. Upon assessment, the resident was found to have two skin tears on her right knee and was unable to recall the events that led to her being outside. The resident's clinical record indicated diagnoses including malignant neoplasm of the kidney, anxiety disorder, and failure to thrive. Staff interviews confirmed that the resident had eloped from the facility and that staff were unable to ensure her safety or monitor her when she was not in the building or accounted for. The administrator acknowledged that the resident was assessed and treated for her injuries after being found outside and stated there was potential for more serious injury due to the lack of supervision while the resident was outside the facility.