Failure to Supervise High-Risk Resident During Smoking Break Leads to Elopement
Penalty
Summary
A deficiency occurred when a resident, identified as high risk for elopement and moderate to high risk for wandering, was not adequately supervised during a scheduled smoking break. The resident's care plan did not include any interventions or plans addressing elopement risk, despite multiple assessments indicating elevated risk. During the smoking break, the assigned activity aide distributed cigarettes and then remained inside the building's doorway due to cold weather, rather than being present on the patio as required by facility policy. There were approximately ten to fifteen residents outside, and no staff was physically present on the patio to monitor them. The resident used a crate to climb onto a gazebo and then jumped over the facility's six-foot fence, leaving the premises without authorization. The absence of direct supervision allowed the resident to elope without immediate detection; staff only became aware of the incident after being informed by another resident. The facility's policy required residents to remain within eyesight of the smoking monitor, no more than 8-10 feet away, and for staff to be present during smoking breaks, but these protocols were not followed. No code was called when the resident left, and the family was not promptly notified. Following the elopement, the resident spent several days outside in cold, inclement weather, sleeping in an abandoned home and at a train station. Upon return, the resident was observed to be unkempt, dirty, and in the same clothes as when he left. Staff interviews confirmed that no new interventions were implemented after the incident, and the resident's family was not informed until days later. The facility's failure to provide adequate supervision and to address the resident's known elopement risk in the care plan directly led to the resident's unauthorized departure and subsequent exposure to unsafe conditions.