Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A resident with a history of aphasia, muscle weakness, unsteadiness, falls, and prior elopement was admitted to the facility and assessed as being at risk for wandering and elopement. The resident's care plan included interventions such as engaging the resident in purposeful activity, placing a wandering device and checking its presence every shift, monitoring the resident's whereabouts every 15 minutes, and identifying de-escalation behaviors. However, documentation revealed that staff did not consistently monitor or document the presence and functionality of the resident's wandering device as required. On the day of the incident, the resident was observed by the receptionist walking out the front doors, which triggered an alarm. The receptionist turned off the alarm, checked on the resident, and saw the resident walking toward a lounge area. When the resident's CNA arrived, the receptionist returned to her duties. The CNA attempted to persuade the resident to return inside, but the resident refused. The CNA then informed the nurse and resumed his work. Subsequently, the nurse and another staff member searched for the resident, who was eventually found walking down the street approximately 0.8 miles from the facility. The resident was returned to the facility without injury. Interviews and record reviews indicated that staff were unaware the resident had eloped until after the fact, and the required facility-wide announcement and immediate notification of the DON or Administrator were not made. The facility's policy required staff to accompany or follow a resident who exits the facility and to alert other staff and organize a search if a resident is missing. These procedures were not followed, and documentation of monitoring the wandering device was lacking.