Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident who had documented dementia, a psychotic disorder with delusions, and a known history of wandering and expressing a desire to leave the facility. An Elopement Risk Evaluation completed months earlier identified the resident as being at risk for elopement, and the care plan reflected this risk due to wandering and verbalizations about wanting to leave. A progress note documented that the resident had been testing door handles and keypads and would run toward the lobby door when it was open, indicating ongoing elopement-seeking behavior. On the night of the elopement event, the resident was last seen by an LPN sitting in a wheelchair at the nurse’s station. When EMS arrived and rang the buzzer for entry, staff remotely opened the coded mag lock door after visually confirming who was entering. Based on the facility’s reenactment, the resident was close enough to the door to keep it from closing and then propelled through the door and down a 25-foot corridor to an outside door that was not alarmed. The resident pushed this outside door open and went outside undetected by staff. EMS later found the resident outside in a wheelchair attempting to go toward the ambulance, and nursing staff then brought the resident back inside. 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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