Failure to Implement Elopement Prevention Measures for At-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free of potential hazards for a resident identified as being at risk for elopement. According to facility documentation, the resident was able to break a window block, kick out the screen, and exit through a first-floor window without injury. The resident subsequently left the premises and was later found at his family home by police, who returned him to the facility. The resident's care plan identified him as an elopement risk and included interventions such as staff checking on his whereabouts throughout the shift and placing his picture at the receptionist desk. Upon review, it was observed that the required photograph of the resident was not present at the reception area, as specified in both the facility's elopement policy and the resident's care plan. Staff interviews confirmed that this intervention was not implemented following the resident's elopement. The failure to follow established policies and care plan interventions contributed to the resident's ability to leave the facility unsupervised.