Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of wandering and elopement was able to exit the secure unit without staff knowledge. The resident, who had diagnoses including dementia, late-onset Alzheimer's disease, anxiety, bipolar disorder, and psychosis, was admitted to the secure unit due to his wandering risk. Despite interventions in his care plan such as frequent location checks, redirection, and activity engagement, the resident managed to open a window in a common room, remove three wood fence pickets, and leave the premises undetected by staff. On the night of the incident, staff did not realize the resident was missing until law enforcement returned him several hours later. The window in the common room was found open beyond the intended limit, and the fence pickets removed by the resident were not visible from a direct line of sight. The staff on duty included a nurse and a CNA, with the CNA being new to the unit and having only partial training. Rounds were reportedly conducted every two hours, but staff avoided entering the resident's room at night to prevent agitation, resulting in the resident not being checked as frequently as policy required. The facility's policy required staff to physically check on residents every two hours to ensure safety, but this was not consistently followed for the resident involved. The resident's care plan identified him as a high elopement risk, and he had a documented history of attempting to leave other facilities. The failure to provide adequate supervision and maintain a secure environment allowed the resident to leave the facility undetected, placing him at risk for harm.