Failure to Supervise Results in Resident Elopement
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to ensure adequate supervision for a resident with dementia, muscle weakness, and major depressive disorder. The resident was admitted to a locked unit and was identified as being at risk for falls and impaired cognitive function. Despite these known risks, staff were unaware of any elopement history for the resident, and there was no process in place to sign out visitors, which contributed to the lack of oversight. On the day of the incident, the resident was last seen in bed and was able to leave the locked unit with the assistance of dietary staff, who did not recognize the individual as a resident. The resident then used the elevator to reach the first floor. At the front entrance, the receptionist mistook the resident for a visitor due to their attire and lack of identifying medical bands, and allowed them to exit the facility. Staff only became aware of the resident's absence after receiving a call from the resident's family member. The resident was located approximately two hours later, 1.2 miles away from the facility, after having accessed high traffic areas and busy intersections. The investigation revealed that the facility's failure to provide adequate supervision and to implement effective processes for monitoring residents and visitors directly contributed to the resident's unsupervised exit. This incident was identified as an Immediate Jeopardy situation due to the high risk for injury.