Failure to Prevent Elopement and Provide Adequate Supervision for At-Risk Resident
Penalty
Summary
A deficiency occurred when a cognitively intact resident, identified as an elopement risk, left the facility unsupervised, obtained alcohol, and was subsequently found by police and transported to the hospital. The resident was known to have a history of wandering and exit-seeking behaviors, as documented in multiple risk assessments and care plans. Despite these known risks, the resident was able to remove his wander guard device and exit the facility without staff knowledge. Staff interviews revealed that the resident was last seen in the building around 1 PM, and the facility did not become aware of his absence until contacted by police several hours later. The facility's policy required frequent monitoring and the use of electronic alert systems for residents at high risk of elopement. However, staff reported that rounds were made every two hours, and there was no formal policy on the frequency of these rounds. The resident's care plan included interventions such as a wander guard, door alarms, and structured routines, but these measures were not effective in preventing the resident from leaving. Staff also noted that the resident had previously removed his wander guard and had a pattern of wandering and exit-seeking, yet he was able to leave undetected. Documentation showed that the resident was alert and oriented at the time of the incident, and his medical records indicated a history of alcohol use and elopement risk. The facility's elopement policy focused primarily on cognitively impaired residents and did not clearly address procedures for cognitively intact individuals with elopement risk. The lack of effective supervision and monitoring allowed the resident to leave the facility, obtain alcohol, and require emergency medical evaluation.