Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, aphasia, encephalopathy, and a history of wandering was not provided with adequate supervision during an off-site medical appointment. The resident was scheduled for transportation to a neurology clinic and required an escort due to his cognitive and behavioral status. Despite multiple progress notes documenting the resident's wandering and confusion, the facility failed to identify him as an elopement risk prior to the incident, and no care plan addressing elopement was in place at the time of the event. On the day of the incident, the resident was transported to his appointment by an outside medical transportation company and escorted into the clinic. After the appointment concluded, the resident was discharged from the clinic and left the premises unsupervised. The transportation driver, scheduled to return later, was unable to locate the resident and notified the facility. Facility staff initiated a search, and the resident was eventually found several hours later, walking miles away from the clinic. Interviews and documentation revealed that there was confusion and miscommunication among facility staff regarding who was responsible for escorting the resident, with some staff believing the resident's representative would attend, while others were aware that the representative could not be present and had requested a staff escort. The facility's elopement risk assessments did not accurately reflect the resident's cognitive impairments and history of wandering, as documented in progress notes and diagnoses. Staff interviews confirmed that the resident had exhibited wandering behaviors and required frequent redirection, yet these observations did not prompt a reassessment of elopement risk or the implementation of appropriate interventions. The lack of a clear process for ensuring supervision during off-site appointments and the failure to update the resident's care plan contributed directly to the resident's unsupervised elopement.