Failure to Prevent Elopement and Ensure Safe Return of High-Risk Resident
Penalty
Summary
A facility failed to provide adequate supervision and ensure a safe environment for a resident assessed as high risk for elopement. The resident, who had vascular dementia and a history of psychoactive substance abuse, was identified on admission as ambulatory with exit-seeking behaviors and a desire to leave the facility. Despite being listed as high risk in the facility's elopement binder, the resident was able to leave the facility unnoticed through an unlocked and unalarmed front door, which was routinely left open during the day. Staff responsible for monitoring the entrance, including receptionists and nursing staff, were either not present or unaware of the resident's elopement risk at the time of the incident. The resident was later found in the community and required emergency department evaluation after testing positive for methamphetamine. Further deficiencies were observed in the facility's handling of the resident's return from the hospital. The facility did not confirm the type of transportation arranged for the resident, who was discharged by taxicab without supervision, despite the known elopement risk. Staff did not meet the resident upon arrival, and the resident did not enter the facility, remaining unattended in the community until located by emergency services. The facility lacked a policy or procedure for ensuring safe or supervised transportation for high-risk residents returning from the hospital, and staff interviews revealed a lack of clarity and responsibility regarding this process. Observations and interviews also revealed that the facility's front entrance was frequently left unlocked and unalarmed, with the expectation that the receptionist would monitor the entrance. However, the reception desk was sometimes left unattended, and staff acknowledged this presented a safety issue for residents at risk for elopement. Additionally, some staff were unaware of which residents were classified as high risk for elopement, and the resident in question was not wearing a wander guard bracelet prior to the incident. The facility's elopement policy did not address verification of safe or supervised transportation for returning residents at risk for elopement.