Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident identified as being at risk for elopement was able to leave the facility unsupervised. The resident had a history of wandering, was disoriented to place, and had impaired safety awareness, as documented in quarterly elopement assessments and the care plan. The care plan included interventions such as the use of a wander guard, structured activities, and frequent checks, but these measures were not sufficient to prevent the resident from exiting the building. On the day of the incident, the resident was found outside in the facility's parking lot by an employee, fully dressed and sitting in a wheelchair, attempting to get into a parked car. The wander guard device was in place and appeared to be functioning, and the door alarm was triggered and sent to staff walkie-talkies. However, staff did not respond to the alarm in a timely manner, allowing the resident to remain outside for approximately five minutes before being returned to the building by a staff member who recognized the resident in the parking lot. Review of camera footage confirmed that the resident was able to hold the door to disarm the locking system and exit the facility. The incident lasted about ten minutes, with the resident outside for half of that time. Documentation and interviews confirmed that the alarm system was operational, but the lack of immediate staff response to the alarm resulted in the resident's unsupervised elopement.