Failure to Prevent Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A facility failed to provide adequate supervision to prevent an elopement incident involving a male resident with severe cognitive impairment, a history of behavioral issues, and recent aggressive and exit-seeking behaviors. The resident, who was admitted with diagnoses including cognitive communication deficit and generalized anxiety disorder, had a BIMS score indicating severe cognitive impairment and was independently ambulatory. Despite a care plan noting behavioral problems and interventions, the resident's risk for elopement was not initially recognized as high, and monitoring protocols were inconsistently implemented. On the day of the incident, the resident was able to leave the facility through an unlocked door, which had no keycode or alarm, and was found by staff approximately 50 feet off the premises in a hazardous area with tall grass, rocks, and uneven ground. Staff interviews revealed that the 15-minute monitoring checks ordered for the resident were not consistently performed or documented, and several staff members were unaware of the monitoring requirement. The DON did not provide specific instructions on how to monitor the resident or what behaviors to observe, nor was a staff member designated to be responsible for the checks. Additionally, the facility lacked physical security measures such as wander guards or door alarms, and residents could exit the building freely. Further interviews indicated that staff were unable to adequately supervise the resident due to competing responsibilities and lack of clear communication. The monitoring sheets for the resident contained missing or incomplete documentation, and staff reported being unable to perform checks during medication passes or breaks. The facility's elopement policy required identification of at-risk residents and specific interventions, but these were not effectively implemented prior to the incident, resulting in the resident's unsupervised exit from the facility.