Elopement Due to Inadequate Supervision After First-Floor Group Activity
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one resident who had been assessed as at risk for elopement. The facility’s own policy defined elopement as a resident leaving a safe area without staff knowledge or entering an unsafe area without staff presence. The resident at the center of the incident had a history that included bipolar disorder, diabetes, moyamoya disease, and moderate cognitive impairment per the MDS. Elopement risk assessments for this resident had fluctuated, with the resident identified as an elopement risk on one assessment and not at risk on two others. The physician had ordered an electronic monitoring bracelet (Wanderguard), and the care plan for behavior symptoms such as wandering and suicidal ideations included checking the Wanderguard placement, providing the device, and using diversions. On the day of the incident, the resident participated in a first-floor group activity (cooking club). After the activity concluded, activities staff began transporting residents back to their home units using an elevator that could only hold four people at a time. One activities aide reported that while transporting residents from the first floor to the upper floors, the resident left the first-floor area near the elevator where she had been waiting to return to her third-floor room. Another statement from the same aide indicated that she had to leave some residents waiting by the elevator due to capacity limits, and when she returned to the first floor, the resident was no longer there. The aide then sought help from other staff to locate the resident. An environmental services employee confirmed seeing the resident and another resident sitting by the elevator, then later finding the resident gone and assuming she had been taken back to her floor before learning she was missing. A code white was called when staff realized the resident could not be found in nearby rooms, restrooms, or on the unit. Multiple staff statements described searching inside and outside the building, including the basement, surrounding doors, parking lot, and nearby alleyways. Staff obtained information from bystanders outside who reported seeing a woman in a wheelchair and pointed out the direction she had traveled. Staff ultimately found the resident outside in a nearby alley, wheeling herself along the berm of the road toward a local convenience store she frequently visited with family during authorized leaves of absence. Progress notes documented that the resident was returned to the facility, was alert and oriented, tearful, and stated she had not intended to cause trouble but wanted to go to the store. A head-to-toe assessment and vital signs check revealed no injuries or distress. During subsequent interviews, staff confirmed that the resident had been left unsupervised near the elevator after the activity and that activities staff did not have ready access to or awareness of an elopement binder listing residents at risk for elopement, contributing to the failure to provide adequate supervision. The surveyors determined this failure created an immediate jeopardy situation for ten residents identified by the facility as at risk for elopement.
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