Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a newly admitted resident with severe cognitive impairment. The resident, who had diagnoses including dementia, cerebral infarction, chronic kidney disease, major depressive disorder, hypertension, and atrial fibrillation, was admitted in the afternoon and was noted to be alert but disoriented, with both short-term and long-term memory problems. The resident was independently ambulatory and used a walker, but did not verbally express a desire to leave the facility. Despite a high score on the facility's Wandering Risk Scale, indicating a high risk for wandering, the resident's baseline care plan did not identify them as an elopement risk. Approximately four hours after admission, the resident eloped from the facility without staff awareness. The last known observation of the resident was after returning from the smoking area with staff and other residents. The resident was not accounted for between 6:15 PM and 6:35 PM, during which time they exited the facility, likely by following a visitor out the front door, which was protected by an access code. Staff did not observe any exit-seeking behavior prior to the incident, and there was no implementation of increased supervision or monitoring, despite the resident's high wandering risk score and cognitive impairment. The resident was found by a community member walking down the street, who then transported the resident to the local police department. The facility was notified of the elopement by the police department. Interviews with staff revealed that although some staff felt the resident needed to be watched for wandering due to confusion and independent mobility, there was no clear communication or directive to increase monitoring or implement more frequent checks. The facility's policy required care planning for residents at risk of wandering or elopement, but the assessment and care plan did not result in additional supervision or interventions prior to the incident. The deficiency was identified as placing residents at risk of harm, serious injury, or death.