Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to implement appropriate interventions, supervision, and safety measures to prevent the elopement of a resident who was identified as being at high risk for elopement and exhibited exit-seeking behaviors. The resident, who had diagnoses including alcohol abuse, encephalopathy, congestive heart failure, lack of coordination, and muscle weakness, was admitted from the hospital and assessed as high risk for elopement shortly after admission. Despite repeated documentation of confusion, unsteady gait, agitation, and multiple attempts to leave the unit, the resident was not consistently provided with the necessary supervision or interventions to prevent elopement. Nursing progress notes documented frequent exit-seeking behaviors, including attempts to open exit doors and wandering near the ambulance entrance. Staff redirected the resident multiple times, and recommendations were made to move the resident away from the exit area and to increase monitoring. However, these interventions were not consistently implemented. On the day of the incident, the resident was last seen in his room, but after a door alarm sounded, staff assumed he was with another staff member and did not verify his whereabouts. A head count was not performed, and the resident was able to leave the facility undetected. The resident was later found by EMS staff laying on the ground near a public road with abrasions to his hands and feet. The incident placed additional residents, who were also identified as being at risk for elopement, in immediate jeopardy due to the lack of effective supervision and safety measures. Staff interviews and facility documentation confirmed that facility policy and procedures for elopement prevention were not followed, and the necessary interventions were not in place at the time of the incident.