Failure to Supervise High-Risk Resident During Outing Leads to Elopement and Hospitalization
Penalty
Summary
A deficiency occurred when a facility failed to provide adequate supervision and accident hazard prevention for a resident under conservatorship with a known high risk for wandering. The resident, who had diagnoses including convulsions, bipolar disorder, psychosis, and major depressive disorder, was placed in a locked unit due to her risk of elopement. Despite this, there was no care plan developed to address her high risk for wandering, as confirmed by record review and staff interviews. On the day of the incident, a CNA was assigned to escort the resident to an outpatient appointment. While waiting at the clinic, the CNA briefly fell asleep and later left the resident unattended to use the bathroom without arranging for another staff member to supervise. Upon returning, the CNA assumed the resident had been called in for her appointment, but later realized she was missing. The resident was not found for over 24 hours, during which time she traveled more than 11 miles from the facility, consumed alcohol, took her prescribed antipsychotic and antidepressant medications, and was eventually found at a hospital emergency department with pneumonia and altered mental status. Interviews with staff revealed that the expectation was for residents to never be left unattended during outings, and that staff should notify others if they needed to step away. The facility's policies required identification of residents at risk for wandering and the development of care plans with specific interventions, but these were not followed in this case. The lack of a resident-centered care plan and failure to maintain supervision directly led to the resident's elopement and subsequent hospitalization.