Resident Elopement Due to Lapse in Supervision
Penalty
Summary
A resident with vascular dementia, aphasia, and a history of falls was admitted to the facility and was not her own responsible party. On the date of the incident, the resident was found outside the facility in the parking lot, unsupervised. The resident was observed by a recreation department staff member and an activity aide, who noted that the resident was attempting to open car doors and expressed a desire to go home and see her family. The staff member spent several minutes convincing the resident to return inside the facility. The facility was unable to determine with certainty how the resident exited the building, but it was believed that she left through a door near the parking lot. At the time of the incident, the resident was not under 1:1 supervision and did not have a WanderGuard device in place. The resident was unsupervised for approximately 3 to 4 minutes before being found and redirected back into the facility. There were no reported injuries or lasting harm as a result of the incident. Interviews and record reviews confirmed that the resident was able to leave the facility without staff supervision, and the facility acknowledged that the resident eloped. The incident highlighted a lapse in supervision and monitoring for a resident with known cognitive impairment and elopement risk, resulting in the resident's unsupervised exit from the facility.