Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, high blood pressure, and difficulty walking eloped from the facility without staff knowledge or supervision. The resident was assessed as cognitively intact with a BIMS score of 15 and had a care plan in place identifying a risk for wandering or elopement. Despite this, staff did not provide adequate supervision, and the resident was able to leave the facility undetected for approximately 22 hours before being located by police. Multiple staff members observed the resident throughout the evening, noting that he was frequently walking in the hallways and was last seen between 8:00 and 9:00 p.m. Staff relied on assumptions about the resident's whereabouts, with some believing he was in the dining room or elsewhere in the building, and did not verify his location during rounds. The facility's practice was to conduct two-hour checks only on incontinent residents, and staff admitted to bypassing the resident's room during rounds due to his usual activity of walking around the facility. The facility was unaware of how or when the resident exited the building, and it was noted that door codes may have been accessible to residents. The lack of consistent supervision and failure to account for the resident's whereabouts resulted in a delay in recognizing his absence. The deficiency was confirmed by the facility's administration, who acknowledged that staff should have realized the resident was missing sooner.