Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent an accident involving a resident with dementia and schizophrenia. The resident, who had a moderate cognitive impairment as indicated by a BIMS score of 8, was allowed to sit outside the front of the building unsupervised after the receptionist left for the day. Despite being assessed as a moderate risk for wandering, the resident was not identified as an elopement risk prior to the incident and was not provided with the necessary supervision to prevent her from leaving the facility premises. On the day of the incident, the resident was last seen approximately 15 minutes before being found walking down the street with her walker, away from the facility. She was observed by a former staff member, who notified facility staff. The resident was subsequently approached and escorted back to the facility by staff without injury. Interviews with staff and the responsible party revealed that the resident had not previously attempted to leave the facility, but she was known to enjoy sitting outside and sometimes expressed confusion or a desire to wait for family members. The facility's staff, including CNAs, LVNs, and administrative personnel, reported that they were aware of policies regarding elopement and wandering, but the resident was not considered an elopement risk before this event. The receptionist, who typically monitored the resident while she was outside, had left and asked the resident to come inside, but the resident remained unsupervised. This lapse in supervision allowed the resident to leave the facility grounds unnoticed, resulting in the deficiency.