Failure to Supervise High-Risk Resident Leads to Elopement
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent an unauthorized leave from the nursing unit, resulting in a resident elopement. A resident with diagnoses including chronic schizophrenia, bipolar disorder, anxiety disorder, and seizure disorder was admitted from a behavioral health hospital with a history of aggression and suicidal and homicidal ideations. Upon admission, the resident was assessed as high risk for elopement, but there was no documentation that a care plan addressing elopement or wandering risk was developed or implemented. The responsible nurse confirmed that interventions such as wander guard placement, supervision, and diversional activities were not put in place for this resident. On the day of the incident, the resident was able to leave the locked nursing unit by following a dietary staff member through code-alarmed doors and then used an elevator to access other parts of the facility. The resident abandoned their wheelchair, took a rollator walker, and exited the building through an unlocked door in the independent living section, eventually being found barefoot in a parking lot. Staff interviews and documentation confirmed that the resident was confused and lacked identification at the time. The facility's failure to follow its own policy for identifying and managing residents at risk for elopement directly contributed to the resident's unauthorized exit from the facility.