Failure to Prevent Elopement of Resident with Dementia
Penalty
Summary
A deficiency occurred when a resident with dementia and multiple comorbidities, including Parkinson's disease, diabetes, and chronic kidney disease, eloped from the facility without staff knowledge. The resident was known to be at risk for elopement, as documented in his care plan, which included interventions such as daily checks of his monitoring device, 15-minute location monitoring, and documentation of wandering behavior. Despite these interventions, the resident was able to remove his monitoring bracelet using an emery board and exited the facility by entering the door code, which was posted in plain sight above the keypad. Staff became aware of the resident's absence only after the wander guard alarm sounded at the front door. A head count and room checks were conducted, and the monitoring device was found discarded in a trash can near the exit. The resident was located by police approximately one mile away from the facility, sitting in a ditch along a busy road, and was returned to the facility with a minor laceration. Interviews with staff revealed that no new interventions had been implemented following the incident, and the door code remained posted above the keypad. Multiple staff members, including CNAs and LPNs, were unaware of any changes to the care plan or additional precautions to prevent further elopement. Further observations indicated that the facility was short-staffed, particularly during evening shifts and weekends, with no staff assigned to monitor the front entrance after office hours. The double doors leading to the front lobby were kept closed, preventing floor staff from observing the front door. The resident continued to express intentions to leave the facility and demonstrated ongoing exit-seeking behavior. The surveyor team was unable to validate the facility's abatement plan, and the Immediate Jeopardy was not removed at the time of the survey exit.