Failure to Prevent Resident Elopement Due to Inadequate Supervision and Environmental Safeguards
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and environmental safeguards to prevent the elopement of a resident with a history of wandering and cognitive impairment. The resident, who had diagnoses including seizures, depression, anxiety, unspecified dementia, and difficulty walking, was identified as being at moderate risk for wandering. Despite this, there was no documented elopement or wandering risk assessment completed prior to the incident, and the resident was able to exit the facility through an emergency exit door near his room. On the night of the incident, staff observed the resident wandering and attempting to leave the building, expressing a desire to go to a store and a bar. Although staff redirected the resident to his room and assisted him to bed, subsequent safety rounds revealed that the resident was missing. A facility-wide search was initiated, and the resident was found outside the facility, attempting to cross the street toward a nearby convenience store. The emergency exit door used by the resident was equipped with an alarm that sounded for 15 seconds before unlocking, but staff interviews indicated that the alarm might not be heard if staff were in resident rooms, and the door could remain unlatched if not properly secured. Interviews with staff revealed gaps in knowledge regarding the operation and security of the emergency exit doors, as well as a lack of awareness of the resident's risk for elopement. The facility's policy required all residents to be assessed for elopement risk upon admission, but this was not completed for the resident prior to the incident. The failure to implement individualized safeguards and ensure staff awareness of exit door security contributed to the resident's ability to leave the facility unsupervised.