Failure to Supervise High Elopement Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident assessed as high risk for elopement. The resident had diagnoses including a right femur fracture, dementia with behavioral disturbance, muscle weakness, and a history of falls, and required substantial assistance with activities of daily living. Multiple assessments identified the resident as a high elopement risk, recommending 15-minute safety checks and the use of a Wanderguard device. Despite these recommendations, the resident was allowed to sit outside the front door when agitated, with staff instructed to check for safety and appropriate clothing. However, documentation and interviews revealed that the required 15-minute safety checks were not consistently performed or documented, and the Wanderguard was not in place prior to the resident's elopement. On the day of the incident, the resident was last seen in the dining room, but during the next scheduled safety check, staff could not locate the resident. A facility search was initiated, and the resident was found a block away, upright in their wheelchair, with no injury identified. Interviews with staff confirmed a lack of awareness and completion of the required safety check forms, and the DON acknowledged that the Wanderguard should have been in place as previously recommended. The failure to implement and document the recommended safety measures resulted in the resident leaving the facility without staff knowledge.