Resident Elopement Due to Inadequate Supervision and Response
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, including Alzheimer's disease and dementia, was able to exit the facility unsupervised. The resident, who was known to wander and had a history of attempting to leave through various exit doors, left the dining room, proceeded down the hall, and exited the facility. The resident was outside for approximately 13 minutes before being located and returned by staff, after a visitor alerted them to the resident's presence in the parking lot. The facility's records and staff interviews confirmed that the resident's cognitive skills were severely impaired, and the resident rarely made decisions or was understood. Staff interviews revealed that alarms sounded when the resident exited, but initial responses were inadequate. Staff members checked the immediate area but did not conduct a thorough search outside or down the street. One CNA stated she was not trained on what to do in the event of an elopement. The incident was only fully recognized after a visitor reported seeing the resident outside, at which point staff located the resident about half a block from the facility. The facility's policy required maintaining a safe environment and preventing elopement, but these measures were not effectively implemented in this case.