Failure to Prevent and Investigate Resident Elopement
Penalty
Summary
The facility failed to provide an environment free from accident hazards related to elopement for a resident with moderate cognitive impairment. The resident, who had diagnoses including cerebral infarction with hemiplegia, altered mental status, disorientation with confusion, and metabolic encephalopathy, was initially assessed as not at risk for elopement. However, the resident was later found outside the facility on the ground near the front entrance, unassisted and without staff knowledge. The resident's wheelchair was found by the front doors, and the resident sustained abrasions to both knees. The front doors were confirmed to be unlocked during the day, allowing anyone to exit freely by pushing the door or pressing the exit button. Staff interviews confirmed that the resident had not previously displayed exit-seeking behavior and that the incident was not immediately recognized as an elopement. The facility's policies required identification of residents at risk for wandering and elopement, as well as thorough investigation and documentation of incidents and accidents. Despite these policies, the facility failed to identify and investigate the elopement event, and the resident was able to leave the building without staff awareness or supervision.