Failure to Prevent Resident Elopement Due to Lapses in Supervision and Device Maintenance
Penalty
Summary
A resident with a history of traumatic brain injury, severe cognitive impairment, psychosis, anxiety, insomnia, bipolar disorder, and schizophrenia was admitted to the facility and had documented elopement attempts since admission. The resident was assessed as high risk for elopement and had medical orders for a Wander Guard device and a sit-stand alarm, with staff instructed to check the Wander Guard placement every shift and to escort the resident to and from meals. Despite these interventions, the resident was left alone in the dining room after dinner while staff were escorting other residents, contrary to the protocol that required the resident to be taken first. During this time, the resident exited the facility through the front doors without staff assistance. Interviews revealed that the Wander Guard device did not alert due to an expired battery, and the sit-stand alarm did not activate because the resident had removed it from his jacket. The receptionist, who usually monitored the doors, was not present on the day of the incident, and there was uncertainty about door monitoring procedures on weekends. The resident was found outside the facility by neighbors, who notified staff. The facility's policy required staff to accompany wandering residents when supervision was necessary, but this was not followed, resulting in the resident's unsupervised exit.