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 wandering was able to elope from the facility. The resident, who had diagnoses including Alzheimer's disease, dementia, and senile degeneration of the brain, was assessed as an elopement risk and had demonstrated exit-seeking behaviors. On the day of the incident, the resident independently propelled himself in a wheelchair out of the facility's front entrance and crossed a busy intersection with multiple lanes of traffic before being found by a pedestrian and returned to the facility by staff. At the time of the event, the lobby area was busy with residents and staff, and a vendor had entered the building with another resident. The receptionist was engaged in conversation with the vendor and did not notice the resident approaching or exiting through the door. The resident was able to leave the building unassisted because the door was not properly secured after the vendor's entry, and staff did not observe the resident's departure. The facility had identified the resident as an elopement risk, with care plans and assessments noting his cognitive deficits, history of wandering, and need for supervision, but these measures were not effectively implemented to prevent the elopement. Interviews with staff and review of facility policies revealed that procedures were in place for monitoring elopement risk residents, including the use of elopement binders, regular rounding, and staff education on elopement prevention. However, on the day of the incident, these procedures were not adequately followed, as the resident was able to exit the facility without detection. The failure to provide adequate supervision and ensure the security of exit doors directly led to the resident's elopement.