Resident Elopement Due to Inadequate Supervision and Staff Communication
Penalty
Summary
A deficiency occurred when a resident identified as high risk for elopement and wandering was left unsupervised in the Activity/Dining Room, which was adjacent to an exit door. The resident, who had diagnoses including dementia with psychosis, multiple rib fractures from recent falls, and severely impaired cognition, required hourly monitoring and specific supervision interventions as documented in their care plan. On the day of the incident, the resident was escorted to the Activity Room by an LVN, who did not confirm that the activity staff member was aware of the resident's elopement risk or the need for close monitoring. The activity staff member, who was not informed of the resident's high elopement risk and was unfamiliar with the resident's medical history, left the resident in the Activity Room at the end of her shift without ensuring that a clinical staff member would supervise the resident. Although two dietary staff members were present in the room, they were not responsible for resident supervision. The activity staff member left to notify a nurse at the nursing station but did not remain with the resident until relieved by appropriate staff. As a result of these actions and lack of communication among staff, the resident was left unsupervised and subsequently exited the facility. The resident was later found by a family member at a bus stop 0.4 miles from the facility, appearing lost and sweating heavily. The incident was reported to the charge nurse after the resident was discovered missing, and interviews with staff confirmed that supervision protocols and communication regarding the resident's risk status were not adequately followed.