Resident Elopement Due to Inadequate Supervision and Access Control
Penalty
Summary
A severely cognitively impaired resident with diagnoses including Alzheimer's disease, anxiety disorder, and osteoporosis was able to exit the facility without staff knowledge. The resident was identified as being at risk for elopement and had interventions in place, such as wearing a wanderguard and being provided with diversions and structured activities. Despite these measures, the resident was able to access an elevator after a dietary aide scanned their badge to open the elevator doors, which allowed the resident to reach the first floor and exit through the main entrance. Observations and interviews revealed that the elevator was equipped with a wanderguard alarm system, which should have sounded when the resident approached the threshold. The system required staff to scan a badge or enter a code to silence the alarm. On the day of the incident, the resident was able to use the elevator and leave the building, walking outside and around the premises for several minutes before being assisted back inside by another resident and staff. Security footage confirmed the resident's path from the elevator to the exterior and eventual re-entry into the facility. Documentation showed that the resident's care plan included elopement risk interventions, and a recent assessment had categorized the resident as low risk for elopement. However, the resident was able to leave the secured area without staff awareness, indicating a failure in supervision and the effectiveness of the elopement prevention measures in place at the time of the incident.