Resident Elopement Due to Inadequate Supervision and Faulty Security Measures
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of psychiatric diagnoses, including bipolar disorder, paranoid schizophrenia, depression, and anxiety, was able to elope from the facility. The resident was assessed as having a severely impaired mental status and was care planned for behaviors such as wandering and attempting to leave the facility without a responsible escort. Despite these known risks, the facility's supervision and environmental safeguards were insufficient to prevent the resident from leaving the premises. On the day of the incident, the resident entered a vending machine room and subsequently exited the facility grounds through a courtyard gate. The gate was supposed to be secured, but the resident was able to manipulate the lock or exploit a gap in the fence, which was in poor condition at the time. Staff did not immediately notice the resident's absence; it was only after a period of time that a CNA discovered the resident was missing, prompting a search. The resident was eventually found outside a nearby store and returned to the facility without injury. Documentation revealed that prior to the incident, facility checks of entrances and exits, including the courtyard gate, were incomplete and not performed on weekends. The lock on the courtyard gate was found to be faulty, intermittently failing to latch, and the fence was described as being in very poor condition. Staff interviews confirmed that the resident was able to leave due to these environmental hazards and lapses in supervision, despite being identified as an elopement risk and having interventions in place on the care plan.