Failure to Supervise High Elopement-Risk Resident and Secure Exit Gate
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident who was a known high risk for elopement, resulting in the resident leaving the facility unnoticed and remaining away for seven days. The resident had schizoaffective disorder, bipolar type, and epilepsy, and was fully ambulatory with an expressed desire to leave the facility. An admission elopement assessment categorized the resident as high risk, with a score of 18, and an updated elopement risk assessment completed on 12/28/25 remained at 18, which met the facility’s threshold for elopement risk. Despite this, the resident was not listed as a high elopement risk in the facility’s elopement binder at the nurses’ station and front desk. On the day of the elopement, a licensed nurse was unable to locate the resident in his room and searched the dining area and common spaces without success, then notified the assigned CNA. The CNA reported that the resident frequently ambulated independently throughout the facility and typically returned on his own. The CNA, who was assigned to the resident from 6:30 A.M. to 2:30 P.M., last saw the resident around 7 A.M. while taking vital signs and, after being informed later that the resident could not be located, only checked the dining room/activity area before returning to complete scheduled room-sweep tasks. The CNA stated he did not look further and later noted that the resident was still not in his room during rounds, and also stated he was unaware that the resident was an elopement risk. Other staff interviews and observations showed that the resident was known to wander around the building, staying in the dining area and outside patio, and that from the patio a resident could access the street through a service/delivery gate that was open during the day. Another CNA confirmed the gate was open during the day and reported not being aware that the resident was an elopement risk. The DON acknowledged that the resident had been assessed as high risk for elopement on initial admission and that residents at high risk should have their pictures and information in the elopement binder, but this resident was not listed. The DON also stated that staff should have visually monitored residents at least every hour. The administrator confirmed that the service/delivery gate observed open during the survey was kept open during the day for deliveries.
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