Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
Facility staff failed to provide adequate supervision and accident prevention measures to protect a resident at high risk for elopement, resulting in an elopement incident. The facility’s policy on “Wandering, Unsafe Resident” was intended to prevent unsafe wandering for residents at risk of elopement, yet the resident, who had dementia with mood disturbance and agitation, depression, cognitive communication deficit, adjustment disorder with anxiety, and conduct disorder, was assessed on December 31, 2025, as being at high risk for elopement. Despite this high-risk status, the resident did not have an elopement prevention care plan in place prior to the incident. On February 12, 2026, at approximately 9:00 a.m., the resident, who resided on the second-floor unit, was able to press on the fire doors for more than 15 seconds, activating the alarm, and then used the stairs to leave the unit. The resident subsequently passed through emergency fire doors on the first floor located next to the entrance doors and across from the receptionist’s desk area. Review of the clinical record and facility investigation confirmed that an elopement prevention care plan for this resident was not developed until after this elopement event occurred.
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