Failure to Supervise and Notify After Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and notification procedures for a resident who was reviewed for elopement. According to the facility's policy, if a resident's whereabouts are unknown and they have not signed out or returned as expected, staff are required to review the sign-out log, notify administrative staff, conduct a search, and contact law enforcement if necessary. In this case, a resident with a history of hip replacement, bipolar disorder, anxiety, and moderately impaired cognition signed out to pay rent but did not return as expected, and there was no documented time of return. Staff interviews and record reviews revealed that nursing staff were aware the resident had not returned by the end of the day but did not attempt to contact the resident or notify administrative staff or law enforcement. The resident was later found to be at home, unable to transfer independently, and required emergency services for evaluation due to a decline in functional status. Staff acknowledged that the resident was not safe at home alone and that the expected protocol would have been to attempt contact and, if unsuccessful, initiate the missing person's policy and notify the administrator. Despite the facility's established procedures, staff failed to follow up when the resident did not return at the expected time, did not attempt to contact the resident or their emergency contact, and did not notify law enforcement or administrative staff in a timely manner. This lapse in supervision and notification placed the resident at risk and did not comply with the facility's own policies for managing missing residents or elopement events.