Resident Elopement Due to Lack of Supervision on Secured Memory Care Unit
Penalty
Summary
A cognitively impaired resident with diagnoses including Alzheimer's disease and dementia, and a history of wandering, exit seeking, and elopement, was able to exit the secured memory care unit of the facility without staff knowledge. The resident was under guardianship and had been assessed as severely cognitively impaired, with care plans in place identifying the risk for elopement and interventions such as diversionary activities and redirection. Despite these interventions, the resident had demonstrated exit-seeking behaviors prior to the incident, including multiple attempts to leave and verbalizing a desire to go home. On the night of the incident, the only CNA assigned to the secured memory care unit left the unit unattended due to a personal emergency, leaving no staff present. During this time, the resident exited the facility through an emergency exit door, which triggered an alarm. Staff became aware of the resident's absence only after the alarm sounded and the resident was discovered missing. The resident was subsequently found by police approximately 1.5 miles from the facility, near a busy intersection, and was returned to the facility. Facility records, including staff witness statements and clinical documentation, confirmed that the resident had a documented history of wandering and exit-seeking, and that the care plan required supervision and specific interventions to prevent elopement. The facility's policy defined elopement as a resident leaving the premises or a safe area without authorization or necessary supervision, placing the resident at risk for harm. The lack of staff presence on the secured unit directly led to the resident's unsupervised exit from the facility.
Removal Plan
- audits of elopement evaluations and care plans
- inservicing staff on elopement procedures
- ongoing monitoring