Resident Elopement Due to Inadequate Supervision and Failure to Identify Elopement Risk
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, mood disorder, anxiety, and bilateral hearing loss was able to leave the facility unattended. The resident, who had moderate to severe cognitive impairment as evidenced by fluctuating BIMS scores and documented poor judgment, was not identified as an elopement risk on initial assessments. Despite a history of wandering at home and family reports of previous elopement behaviors, the resident was allowed to sit outside the facility unsupervised. On the day of the incident, the resident left the premises without staff knowledge and was later found approximately one mile away near a freeway by a staff member. Interviews and record reviews revealed that staff supervision protocols for residents sitting outside were inconsistent. There was no designated staff assigned to monitor residents on the patio, and staff relied on periodic checks or visual observation from inside the building. The resident was not signed out, and there was no documentation of his departure. Staff and family interviews confirmed that the resident was not capable of safely leaving the facility alone due to his cognitive impairment, and the area outside the facility included busy streets and a nearby freeway, increasing the risk of harm. Documentation of the incident was incomplete, with missing incident reports and inadequate nursing notes regarding the event. The facility's elopement policy required investigation, reporting, and documentation of missing residents, but these procedures were not fully followed. Staff interviews indicated confusion about supervision responsibilities and criteria for allowing residents to leave the building independently. The lack of adequate supervision and failure to implement appropriate safety measures for a cognitively impaired resident led to the resident's unsupervised departure from the facility.