Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident, assessed as high risk for elopement due to diagnoses including dementia, hypertension, type 2 diabetes, anxiety, and depression, was left unsupervised on a secured memory care unit. The resident had a history of restlessness, attempts to leave the unit, and expressed a desire to go home, as documented in multiple nurse notes. The care plan and risk assessments identified the need for frequent checks and supervision, especially during high-risk times. On the day of the incident, the staff member assigned to supervise the secured unit left the area unattended. The charge nurse had instructed a CNA to relieve the current staff member for a lunch break, but the CNA failed to go to the unit as directed and was observed elsewhere in the facility. During this period, the resident eloped from the secured unit, using a chair and trash can to climb over the courtyard fence. The resident was later found at his previous home address, approximately one mile from the facility, and was returned without injury. Interviews with staff confirmed that the CNA assigned to the unit was not present at the time of the elopement, and the absence of supervision directly contributed to the resident's ability to leave the facility. Documentation and staff statements indicated that the resident's risk for elopement was well known, and the failure to provide adequate supervision resulted in the resident's unsupervised departure from the secured unit.