Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with severe cognitive impairment and a known risk for wandering. The resident, who had diagnoses including altered mental status, encephalitis, and unspecified lack of coordination, was assessed as having severe cognitive impairment and required partial to moderate assistance with mobility. Initial elopement risk assessments did not identify wandering behaviors, but subsequent assessments documented wandering, confusion, and exit-seeking behaviors. Despite these findings, the resident's care plan was not updated to reflect the increased risk for wandering and elopement until twenty days after the risk was identified. On the day of the incident, the resident independently left the skilled unit and navigated to another area of the facility without staff knowledge. Multiple staff statements indicated that the resident was seen in various locations prior to the elopement, but staff did not maintain adequate supervision or respond to the resident's movements. The wander guard system, which was intended to prevent such incidents, was disabled by a staff member for another resident without confirming that other at-risk residents were not in the vicinity. As a result, the resident was able to exit the unit undetected, and the alarm did not sound when the resident left the area. Staff interviews and documentation confirmed that the alarm system was not properly monitored and that staff were unaware of the resident's whereabouts during the incident. The failure to provide adequate supervision and to ensure the effectiveness of the wander guard system resulted in the resident's elopement, creating an immediate jeopardy situation. The deficiency was confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged that the facility did not meet the required standard of supervision for residents at risk for wandering and elopement.