Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of exit-seeking behavior, and multiple psychiatric and neurological diagnoses was able to leave the facility without staff awareness or supervision. The resident was missing from the facility for several hours and was later found wandering unprotected along a road, eventually being located approximately three miles away. The resident's medical records indicated a history of wandering, exit-seeking, and recent admission with poor adjustment, as well as a history of substance abuse and homelessness. The care plan identified the resident as an elopement risk and included interventions such as a wander guard device and hourly visual checks. Despite these interventions, facility staff failed to adequately monitor the resident. Monitoring records showed that checks for exit-seeking behaviors and the function and placement of the wander guard device were ordered and documented, but the resident was still able to elope. Upon return, it was discovered that the wander guard device was not functioning. Additionally, the facility's entrance/exit doors were found to be inadequately supervised during certain hours, with one exit door alarmed but unlocked, and the entrance door code posted publicly. There was no receptionist present to supervise the entrance door overnight, and staff acknowledged that more frequent visual checks could have been performed. The resident was evaluated at a local emergency department after being found, presenting with increased confusion and alcohol intoxication. The facility's policy required systematic monitoring and management of residents at risk for elopement, including assessment, intervention, and monitoring for effectiveness. However, the failure to ensure the effectiveness of interventions and adequate supervision directly led to the resident's unsupervised exit and subsequent elopement.