Failure to Prevent Elopement Due to Inadequate Supervision and Security Protocols
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for elopement received adequate supervision and assistance devices to prevent accidents. The resident, who had diagnoses including dementia, psychotic disorder with delusions, and anxiety, was known to be ambulatory and had a documented history of elopement risk, including a prior incident where the resident left the building and was returned by security and police. The care plan and physician's orders specified 30-minute visual checks for safety, and the resident had refused to wear a wander guard. Despite these measures, documentation showed that staff were monitoring the resident every two hours instead of every 30 minutes as ordered, and the last visual check was recorded at 4:00 PM, after which the resident was not accounted for until much later. On the day of the incident, the resident was last seen by staff at 4:00 PM talking with a family member. Security Guard #1, stationed at the front desk, opened the main entrance door for the resident, allowing them to exit the building unsupervised. The security guard did not follow facility protocol, which required screening every person prior to leaving the building to ensure residents do not leave without authorization. The security guard later admitted to this failure and was terminated. Staff did not become aware that the resident was missing until 5:35 PM, at which point a search was initiated, and law enforcement was contacted. The resident was later found by emergency services and admitted to the hospital with diagnoses of encephalopathy secondary to hypothermia and acute kidney injury. Interviews with staff revealed inconsistencies in monitoring practices and a lack of clarity regarding responsibility for the resident's supervision. Certified Nursing Assistants and nursing staff described being occupied with other duties and not performing the required 30-minute checks. The security guard failed to recognize the resident as someone at risk for elopement, despite the resident's picture being posted at the security desk. The facility's policies for elopement prevention and front desk security monitoring were not followed, resulting in the resident's unsupervised exit and subsequent harm.