Failure to Supervise Resident Resulting in Elopement
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's dementia and a history of wandering was not adequately supervised, resulting in the resident leaving the facility unsupervised. The resident, who had a BIMS score indicating intact cognition but was known to wander and required supervision for safety, was last seen walking toward the dining room. Staff assumed the resident had entered the dining room, but when a door alarm sounded, staff failed to immediately and thoroughly investigate the cause of the alarm or confirm the resident's whereabouts. Instead of conducting a prompt and comprehensive search, staff turned off the door alarm after a brief visual check and did not go outside to verify if anyone had exited the building. It was only after the resident could not be located inside that a head count and neighborhood search were initiated. The resident was eventually found several blocks away and returned to the facility without injury. Interviews revealed that staff did not follow the facility's policy, which required a visual check of the area around the exit, including outside the building, when a door alarm sounded. Documentation showed that the resident was considered at moderate risk for elopement due to his diagnosis and history, and the care plan directed staff to monitor and redirect him as needed. Despite these interventions, staff actions were insufficient to prevent the resident from leaving the facility, and the required protocols for responding to door alarms and missing residents were not followed as outlined in facility policy.