Failure to Prevent Elopement Due to Inadequate Supervision and Staff Training
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of wandering, and multiple prior elopement attempts was not provided adequate supervision and assistance to prevent an elopement. The resident was able to leave the facility after a Certified Nursing Assistant (CNA), who was unfamiliar with the residents and had not received training on elopement risks, entered the front door code and allowed the resident to exit the building. The CNA did not recognize the individual as a resident and failed to notify other staff after the resident left the facility. No immediate action was taken to locate the resident, and the incident was not reported to other staff members at the time. The resident was not discovered missing until the following morning, when a staff member driving to work found the resident approximately 1.7 miles from the facility, near a busy road, in below-freezing temperatures with snow on the ground. The resident was inadequately dressed for the weather, wearing only a jacket, lightweight shoes, and no gloves or hat. Upon return to the facility, the resident was assessed and found to have decreased oxygen saturation, wheezing, and cold extremities. The resident was subsequently sent to the emergency department for further evaluation due to abnormal lung findings and a potential pulmonary embolism. The facility's policies required systematic monitoring and management of residents at risk for elopement, including staff awareness and adequate supervision. However, the CNA involved had not received orientation or training regarding residents at risk for elopement and did not consult with other staff when unsure about the resident's identity. Additionally, there was a lack of effective communication between shifts, as the overnight CNA did not receive any report or information about the resident's risk or whereabouts. These failures in supervision, staff training, and communication directly led to the resident's unsupervised exit and subsequent exposure to hazardous conditions.