Failure to Supervise and Address Elopement Risk
Penalty
Summary
The facility failed to provide adequate supervision and address elopement risks for a resident with a history of dementia, diabetes mellitus, generalized anxiety disorder, and encephalopathy. The resident, who was mobile in a wheelchair and known to self-propel quickly, was able to elope from the facility through the front door during the early morning hours. Although the alarm was triggered and staff returned the resident to the facility within 30 seconds, the incident was not immediately reported to the Director of Nursing (DON) or documented in detail, and no immediate interventions were implemented following the event. Subsequent interviews revealed that the DON and Care Plan Coordinator were unaware of the elopement attempt until weeks later, resulting in a delay in revising the resident's care plan and implementing new interventions. The care plan was not updated with additional safety measures until after a second elopement occurred. Staff on duty during the incidents reported that the resident was actively exit-seeking and required frequent redirection, but supervision and monitoring were insufficient to prevent the resident from leaving the facility undetected. Facility policies required immediate notification of administration and the DON in the event of an elopement or attempted elopement, as well as prompt implementation of increased monitoring and individualized safety interventions. These procedures were not followed after the initial elopement attempt, and documentation of the incident and subsequent monitoring was lacking. The failure to act according to policy and provide adequate supervision contributed to repeated elopement events for the resident.