Failure to Supervise and Care Plan for Wandering Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and implement person-centered interventions to prevent accidents, specifically elopement, for a resident with moderate cognitive impairment and a history of wandering. Despite multiple nursing progress notes documenting the resident's increasing restlessness and wandering throughout the facility at night, no individualized care plan or interventions addressing wandering or elopement risk were initiated. The facility's policy required staff to identify at-risk residents, assess for risk factors, and include safety interventions in the care plan, but these steps were not followed for this resident. The resident, who had diagnoses including traumatic brain injury, diabetes, and hypertension, was noted in several progress notes over multiple days to be wandering from room to room and to common areas during the night. There was no documented history of wandering prior to admission, but staff observations indicated a pattern of nocturnal wandering. Despite this, the care plan was not updated to reflect these behaviors, and no elopement risk assessment was conducted after the resident was found outside the facility several blocks away. After the elopement incident, staff placed the resident on 15-minute safety checks, but the care plan and risk assessment were still not promptly updated. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's wandering behaviors, and exit doors were described as unsecured and unmonitored, allowing the resident to leave the facility unsupervised. The failure to recognize and address the resident's wandering and elopement risk resulted in the resident being found offsite by a community member.