Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a BIMS score of 03 and diagnoses including dementia and cerebral amyloid angiopathy, was admitted to the facility and initially assessed as low risk for elopement. Despite this, a care plan was developed that included interventions such as engaging the resident in purposeful activity, providing reorientation, and conducting 15-minute checks. However, the resident was able to leave the care center building and was found sitting on a bench approximately 700 feet away, outside the facility and not visible from the care center. The resident had been unsupervised for about an hour before being discovered by staff from the independent living building next door. Staff interviews confirmed that 15-minute checks were supposed to be in place for residents at risk of wandering or elopement, but the resident was able to leave the premises without detection. The facility's policy defines elopement as a resident leaving the premises or a safe area without authorization or necessary supervision. Documentation and staff statements revealed that the resident was found hot and sweaty, and required assistance from emergency services upon return. The incident demonstrated a failure to provide adequate supervision and to ensure the area was free from accident hazards, resulting in the resident's elopement.