Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment. The resident, who had a BIMS score of 7 indicating severe cognitive impairment, required substantial to maximum assistance with transfers and ambulation, and had a history of elopement and exit-seeking behaviors. The care plan included the use of a wander guard, regular checks of the device, and staff assistance with mobility and reorientation. Despite these interventions, the resident was able to leave the facility unsupervised. On the morning of the incident, staff statements and interviews revealed that a CNA heard a door alarm and subsequently noticed the resident was missing from their room. Staff searched both inside and outside the building, and the resident was eventually found at the front door, cold and confused, wearing a wander guard that was still functional. Staff accounts indicated that the resident had attempted to leave the facility multiple times in the days prior, and another resident reported seeing the individual moving quickly down the hall earlier that morning. The nurse on duty had exited the building around the time of the incident, and the front door alarm was triggered, but the resident was not immediately located. The facility's elopement risk evaluation and care plan identified the resident as high risk for elopement, with a history of not responding to redirection and attempts to remove the wander guard. The facility's missing patient response plan outlined procedures for searching and notification, but the resident was able to exit and re-enter the building without staff immediately realizing. There were no operational cameras, and staff were unclear about certain security procedures, such as locking the sun room door, under new management.