Failure to Adequately Supervise High-Risk Resident Leading to Repeat Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate monitoring and supervision to prevent elopement for a resident identified as high risk. The resident was admitted to the secured unit with major depressive disorder, bipolar disorder, opioid dependence, and alcohol dependence, and had an elopement risk score of 14 on admission and 16 on a later assessment, both above the facility’s threshold of 10 for elopement risk. The resident’s BIMS score of 15 indicated full cognitive function. An initial wandering/elopement care plan was created due to attempts to exit the unit unattended, alcohol abuse, and mental health illness, with interventions including resident education about supervision when going outside the unit, maintaining a safe and hazard-free environment, and providing structured activities. After a first elopement through the room window, an actual elopement care plan was developed that included a 1:1 sitter until psychiatric evaluation, every 30-minute monitoring, moving the resident to another room, and social services involvement. Despite these identified risks and prior elopement, the resident eloped a second time through the room window without being detected by staff. On the night of the second elopement, staff observed the resident in his room around 11:00 p.m., and a CNA saw him walking in the hallway near his room between approximately 11:00 and 11:20 p.m. The resident later reported that he waited until after staff made their rounds and then left through the window around 11:00 p.m. At approximately 11:30 p.m. to midnight, nursing staff discovered the resident was not in his room and found the window open with the screen removed. Law enforcement was contacted, and the resident was located at a nearby convenience store and returned to the facility around midnight to 1:00 a.m. Interviews with the DON and Behavioral Health Director confirmed the resident was alert and oriented, and the DON stated that every 30-minute monitoring had been discontinued after the team developed a plan. The facility’s written policy on wandering and elopement stated that the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment.
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