Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for one of four sampled residents when the resident left the facility without staff knowledge and was missing for five hours. The resident, who had diagnoses including spinal stenosis of the cervical region and abnormalities of gait and mobility, was last seen by an LVN in the hallway around 5:00 AM. Shortly after, staff noticed the resident was not in his room during rounds, prompting a search and notification of the supervisor. The resident was eventually found at an adjacent facility and taken to the hospital. Record review and interviews revealed that the resident did not have authorization or a physician's order to leave the facility. The facility's policy requires constant supervision for residents not authorized to leave, and elopement assessments are conducted for those at risk. The administrator acknowledged that insufficient supervision contributed to the incident, as the resident was able to exit the building without staff awareness.