Failure to Follow Elopement Protocol Resulting in Resident Leaving Facility Overnight
Penalty
Summary
The deficiency involves the facility’s failure to follow its elopement and supervision protocols, resulting in a resident leaving the building, traveling out of town, and remaining out overnight without staff knowledge. The resident had diagnoses including schizophrenia, anxiety disorder, depression, gait and mobility abnormalities, and other lack of coordination, but had an intact cognition with a BIMS score of 15/15. The facility’s policy on Elopements and Wandering Residents stated that residents at risk for elopement would receive adequate supervision to prevent accidents or elopements. On the day of the incident, the resident left the facility through the lobby without notifying nursing staff or being signed out, which differed from their usual practice of informing a nurse and signing out when going out. The resident later reported that they told a CNA they wanted to go out but did not inform a nurse or obtain a formal sign-out. RN staff last recalled seeing the resident around late morning to midday and did not see the resident again before the end of the shift, nor did they report the lack of contact in shift handoff. During the evening, the resident’s dinner tray was delivered and later found untouched, and the CNA reported this to the LPN, initially assuming the resident was out smoking. Progress notes showed that the resident was not seen in their room at multiple checks in the late afternoon and early evening, and a search was not escalated until it became clear later in the evening that the resident was not in the facility. By that time, the resident had already left, obtained a ride to a train station, traveled by public transportation to their hometown, missed return buses, and spent the night in a hospital lobby before returning the next morning. The facility’s failure to adequately monitor the resident’s whereabouts, recognize and act promptly on the missed meal and absence from the room, and ensure adherence to the sign-out process led to the resident’s elopement in violation of the facility’s policy requiring adequate supervision to prevent accidents or elopements.
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