Failure to Prevent Elopement Due to Inadequate Supervision and Rounds
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident who required increased visual checks. The resident, who had a diagnosis including Wernicke's encephalopathy and a moderate cognitive impairment (BIMS score of 8), was identified as a wandering risk and had previously expressed a desire to leave the facility. Despite being placed on a secured dementia unit and having a care plan that called for increased visual checks and window alarms, the resident was able to exit the facility by going out a window and crawling under a fence. The window alarms were not yet installed at the time of the incident, and staff monitoring was insufficient, as rounds were not conducted as required. Staff interviews and record reviews revealed that the resident was not checked on regularly during the night shift, with some staff admitting to only seeing the resident at the beginning of the shift or not conducting rounds at the required intervals. Video review confirmed that staff were not performing rounds and were observed sleeping during the shift. The resident was found by police several miles from the facility and returned with minor abrasions and bruising. The facility's policy required adequate staffing and supervision at all times, which was not maintained, resulting in neglect of the resident.