Unsupervised Exits and Failure to Enforce Leave of Absence Procedures
Penalty
Summary
Failure to ensure a hazard-free environment and adequate supervision occurred when two residents exited the facility without following the required leave of absence (LOA) procedures and without staff awareness. One resident with alcohol dependence, opioid dependence, frequent falls, and moderate cognitive impairment (BIMS 11/15) left the building without signing out in the LOA log or notifying staff. This resident had an admission elopement assessment score indicating low risk and a physician order permitting LOA with medications and supervision. Video review showed the resident walking through the lobby toward the front door wearing outdoor clothing, passing the front desk without being acknowledged by the staff member covering the desk, who later stated they were unsure if the person was a resident or a family member. After the cognitively impaired resident exited, staff became aware of the situation only when a CNA received a call from a family member reporting a possible resident off property walking with a walker near a local restaurant, observed to fall to their knees and then continue walking. A nurse then searched outside in dark, cold, and slippery conditions and located the resident inside a nearby restaurant. Upon return, assessment identified an abrasion on the knee and a skin tear below the right anterior knee. In an interview, the resident stated they had simply walked out the front door, spoken with someone's family outside, and proceeded toward a store for snacks, adding that no one spoke to them as they left and that they must have forgotten to sign out. In a separate incident, another resident who routinely exited and re-entered the facility multiple times daily for smoking also left the facility without signing out in the LOA book, meaning nursing staff were not notified of the departure. This resident was documented as cognitively intact with a BIMS score of 15/15 and had been assessed as at no elopement risk. Staff interviews revealed that the resident's frequent LOAs were known to reception staff, the DON, and the social worker, and that the expectation was for LOAs to be logged at the nurse station and for nurses to be informed of departures, even when a CNA accompanied the resident. Staffing on the resident’s wing at the time was reported as two nurses and three CNAs for 68 residents, with staff indicating they should have three nurses and four CNAs and describing frequent short staffing due to call-offs and scheduling.
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