Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident exited the facility without staff knowledge or supervision. The resident had a history of elopement at home, wandering behavior, and an elopement risk score of 6.0 upon admission. The resident was admitted with diagnoses including seizures and depression, and had fluctuating capacity to make medical decisions. The Minimum Data Set assessment indicated the resident was cognitively intact and required limited assistance for activities of daily living. Despite these risk factors, the resident was last observed in bed early in the morning, and staff were unable to locate the resident during subsequent checks, prompting a facility-wide search. Interviews with staff revealed that the resident was ambulatory and frequently walked around the facility. The Director of Nursing stated that the elopement was unexpected, as the resident had not previously shown signs of wanting to leave. The facility's policy on safety and supervision emphasized the importance of targeting interventions to reduce individual risks and providing adequate supervision. However, the lack of effective supervision allowed the resident to leave the premises unnoticed, constituting a failure to prevent accidents as required by facility policy.