Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known history of elopement was not provided with adequate supervision, resulting in the resident eloping from the facility. The resident, who had diagnoses including dementia, gout, acute kidney failure, Type 2 diabetes, oropharyngeal dysphagia, lack of coordination, and major depressive disorder, was wearing a Wanderguard device as ordered by the physician. Despite this, the resident was able to exit the facility undetected during the night, and staff did not become aware of the elopement until notified by an external party. The facility's records indicated that the Wanderguard was checked regularly, but there were missing timestamps for the device checks on the day of the incident. The facility failed to complete an elopement assessment for the resident prior to the incident, despite the resident's history of exit-seeking behavior and previous elopement incidents reported by the family. The initial social history and assessment did not document any behavioral concerns, and the family was not asked about prior elopement behaviors during admission. The only elopement evaluation on file was completed after the resident had already eloped, which identified the resident as being at risk for elopement. Staff interviews confirmed that there was no prior knowledge or documentation of the resident's elopement risk before the incident. Facility policy on elopement did not include specific guidance on supervision, accident prevention, or proactive measures to prevent elopement. The incident report and staff interviews revealed that the resident was able to leave the facility through an exit door that did not alarm, and staff were unaware of the resident's absence until contacted by someone outside the facility. The resident was later found at a nearby apartment complex with minor injuries and was subsequently transferred to a secure unit at another facility.