Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including dementia, anxiety disorder, and brain cancer, and who was assessed as high risk for elopement, was able to leave the facility unsupervised through the main entrance. The resident, who was non-ambulatory and used a wheelchair, was found outside in the parking lot by a nurse aide, approximately twenty minutes after leaving the building. At the time of discovery, the resident was not wearing her assigned wanderguard bracelet, which was intended to prevent such incidents. Staff interviews and record reviews revealed that the resident's care plan included interventions such as placement of a wanderguard, redirection from exits, and notification of the DON for exit-seeking behaviors. However, on the day of the incident, the nurse assigned to the resident did not check for the presence of the wanderguard at the start of her shift, as required by physician orders. The nurse aide who last provided care to the resident could not recall if the wanderguard was in place, and the receptionist responsible for monitoring the main entrance was not present, as the incident occurred on a weekend when no receptionist was scheduled for that time. Facility staff, including the maintenance director and receptionist, described the wanderguard system and monitoring procedures, noting that the main entrance is typically monitored by a receptionist during certain hours and that the system is designed to alarm and lock if a resident with a wanderguard approaches. Despite these measures, the resident was able to exit undetected, and staff only became aware of the incident when the resident was found outside without her wanderguard. The event highlighted lapses in supervision and failure to ensure the effectiveness of elopement prevention interventions for a high-risk resident.