Failure to Adequately Supervise Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one resident. The resident was admitted with diagnoses including atrial fibrillation, unsteadiness on feet, muscle weakness, and Alzheimer’s disease, and the MDS dated 5/29/24 documented severe cognitive impairment. A progress note from the day of admission stated the resident was alert with confusion and did not always follow commands. On the evening of admission, a nurse aide reported seeing the resident in her room at approximately 9:10 p.m., noting that the resident kept getting up and that aides repeatedly redirected her back to her room. Around 9:30 p.m., during a room check and inventory, the aide discovered the resident was no longer in bed or in the bathroom and could not be located in nearby rooms. The aide alerted other staff that the resident was missing, and a search of the unit, basement, laundry room, fire exits, outside areas, and around other campus buildings was initiated. During this time, the RN was notified and documented that the resident had eloped and that staff were instructed to conduct a thorough search of the facility and surrounding areas. The facility also notified the attached personal care home and law enforcement after the resident was not located within 15 minutes. The resident was ultimately found off the unit in the basement area of the attached personal care/assisted living building, sitting by the time clock, and was then returned to the facility. The facility later acknowledged they were unable to determine the exact exit path, but indicated an obvious route would have been through the front doors into the attached personal care home and down an elevator to the lower level. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent this elopement.
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