Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a high risk for elopement was removed from a secured unit to attend an activity in the main dining room. The resident, who had diagnoses including catatonic schizophrenia, dementia, chronic obstructive pulmonary disease, hemiplegia, and anxiety, was known to wander and required secure unit placement as documented in his care plan and elopement risk assessment. Despite these precautions, the resident was brought to the dining room for a carnival event and left unsupervised, which was contrary to his care plan interventions that specified he should remain on the secured unit. During the event, the resident was left at a table in the dining room by a CNA, who believed the ADON had accepted responsibility for supervision. However, the ADON did not acknowledge taking over supervision and was already monitoring other residents from the secured unit. The resident was left unattended, and staff did not maintain direct supervision. The resident exited the facility through a dining room door that did not alarm, and his absence was not immediately noticed by staff. He was found outside the building walking on a sidewalk and was returned to the secured unit without injury. Interviews with staff revealed confusion and lack of clear communication regarding who was responsible for the resident's supervision while off the secured unit. The CNA who brought the resident to the activity was new and had not ensured a proper handoff of supervision. The charge nurse was unaware the resident had left the unit, and the ADON did not accept responsibility for the resident. The door alarm malfunctioned or was disabled, allowing the resident to exit undetected. The incident was identified as past non-compliance and resulted in an Immediate Jeopardy situation.