Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The facility failed to adequately supervise and monitor the whereabouts of a resident who was admitted with significant psychiatric diagnoses, including bipolar disorder with psychotic features, schizoaffective disorder, and a recent history of hearing voices instructing self-harm. Upon admission, the resident was identified as being at risk for elopement, and behavioral monitoring was indicated as a primary focus. Despite these risk factors, the resident was able to leave the facility without notifying staff, and their whereabouts remained unknown following the incident. Record reviews revealed inconsistencies and incomplete documentation regarding the resident's expressed desire to leave against medical advice (AMA). Although the resident signed an AMA form, it was missing a date and staff witness signatures, and the physician order summary did not indicate a discharge. Staff interviews indicated that the resident had previously expressed a wish to leave, but was convinced to stay, leading to the incomplete processing of the AMA form. On the day of the incident, staff discovered the resident missing during routine rounds, and subsequent searches and notifications were made to authorities and facility leadership. Observations during the survey found that staff were not consistently monitoring resident whereabouts, particularly during shift changes. No staff were observed making rounds or present at key monitoring locations such as nurses' stations, and certain facility areas, such as a service elevator, were not visible from staff workstations. Staff interviews confirmed that resident accountability was not ensured during shift changes, increasing the risk of elopement for residents identified as high risk.