Failure to Prevent Unsafe Wandering and Elopement of Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for cognitively impaired residents, resulting in multiple incidents of unsafe wandering and elopement. Three residents with severe cognitive impairment and a history of exit-seeking behaviors were able to leave the facility unsupervised on separate occasions. In each case, the residents were identified as being at risk for elopement, had documented exit-seeking behaviors, and were equipped with wander alarm bracelets. Despite these precautions, staff did not consistently monitor alarms or verify the whereabouts of residents when alarms were triggered. One resident with dementia and a history of attempted elopement exited the facility through the front door, setting off the alarm. Staff turned off the alarm without checking on residents with wander alert bracelets, and the resident was later found unsupervised in the parking lot by a staff member on break. Another resident with severe cognitive impairment and a wander alarm bracelet was found wandering in the parking lot by a visitor, with no staff aware of the resident's absence. A third resident with a traumatic brain injury and severe cognitive impairment was found outside the facility by a staff member leaving work, after having exited without staff knowledge. Observations revealed that the facility's entrance doors did not have audible alarms, and staff were not consistently present to monitor exits. The physical layout allowed residents to move freely between the skilled nursing facility and an adjoining assisted living facility, with unsecured hallways and proximity to busy roads. Staff interviews confirmed a lack of awareness regarding the functionality of alarm systems and the risks posed by unsecured exits. The facility had not conducted elopement drills or reassessed all residents for elopement risk following these incidents.