Failure to Prevent Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and did not provide adequate supervision to prevent accidents for one resident with severe cognitive impairment. The resident, a male with diagnoses including anoxic brain damage, schizoaffective disorder, and anxiety disorder, was assessed as having a severe cognitive deficit and was known to wander, requiring a wander guard for safety. Despite these precautions, the resident was able to leave the facility unsupervised when another resident propped open a door to smoke, allowing the resident to exit undetected. On the night of the incident, the resident was last observed in bed at 10:15 PM, but by 11:05 PM, he was found outside the facility and was returned by local police after being discovered across the street. The resident was wearing his wander guard at the time, but the door being propped open bypassed the intended security measures. The facility's records indicate that the resident was outside the facility for approximately 20 minutes before being returned, and no injuries were noted upon assessment. Interviews with staff and review of facility documentation confirmed that the door was propped open by another resident, which directly led to the elopement. The facility's elopement policy required staff to ensure resident safety and monitor doors, but this was not effectively implemented, resulting in the resident's unsupervised exit. The deficiency was identified as past non-compliance at the Immediate Jeopardy level, as the failure to supervise and secure the environment exposed residents to significant safety hazards.