Failure to Prevent Elopement Due to Inadequate Supervision and Environmental Hazards
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for a resident at risk for elopement. The resident, a male with severe cognitive impairment, non-Alzheimer's dementia, anxiety, hypertensive heart disease, osteoarthritis, psychotic disorder, and intervertebral disc degeneration, was identified as high risk for elopement and placed in a secured unit. Despite this, the resident was able to exit the facility unsupervised by forcing open a window in a room near the TV area, which was found to have a compromised locking mechanism and no alarm at the time of the incident. On the night of the incident, staff last observed the resident in the TV room. During routine activities and medication administration, the resident was not directly supervised and was able to leave the secured unit undetected. Staff initiated a search and discovered a broken window with evidence of forced exit, including a sheared bolt and disturbed bushes outside. The resident was later found by emergency services in a nearby area, having sustained superficial abrasions and a compression fracture of the lumbar spine. Interviews with staff revealed that the window in question did not have an alarm prior to the incident and that the resident had not previously exhibited elopement behavior, though he was known to wander and was physically strong. The facility's elopement prevention policy required regular checks of exit devices, but the absence of an alarm and the compromised window allowed the resident to elope. Staff were occupied with other residents during the time of the incident, and the lack of direct supervision contributed to the resident's ability to leave the facility undetected.