Resident Elopes Through Unsecured Side Door During Staff Party
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free of accident hazards and to provide adequate supervision to prevent elopement for one resident identified as at risk. The facility had an elopement policy stating it would identify, prevent, detect, and respond promptly to resident elopement, and the resident’s care plan documented that he was at risk for elopement due to independent ambulation, paranoid schizophrenia, anxiety, and hallucinations/delusional thoughts. The care plan goals included that the resident would not leave the facility unsupervised and that staff would take appropriate steps to prevent and detect elopement, including use of electronic door locks, staff education, and staff control of door access. The resident had diagnoses including schizoaffective disorder, vascular dementia, psychotic disturbances with hallucinations and delusions due to a known physiological condition, muscle weakness, and dysphagia. A recent MDS showed he was cognitively intact with a BIMS score of 15, had disorganized thinking that did not fluctuate, and was independent with mobility and had no range-of-motion limitations. Progress notes documented that on the day of the incident, a community member called the facility reporting that he believed a facility resident was walking down the street. Facility staff went to the location, verified the resident’s identity, and found him unharmed, but he refused to get into the vehicle to return and stated, “ya’ll are trying to kill me,” demanding that police be called and agreeing to return only with an officer. Interviews and record review showed that the resident was able to exit the building without staff supervision during a staff Christmas party. Staff reported that the resident likely went out behind someone when a door was opened, and that the exit door on the 200 Hall had previously been equipped with a latch/hook used to hold it open for moving a shower bed. The DON and Administrator stated that at the time of the elopement, the side door used for the shower bed was not secured after a staff member brought the shower bed in, allowing the resident to leave the facility. The Administrator confirmed that this occurred while all staff were present at the Christmas party and stated that staff assigned to residents were expected to be accountable to them.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.