Failure to Prevent Elopement of At-Risk Resident Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a documented history of elopement and wandering behaviors was able to leave the facility unsupervised and without staff knowledge. The resident, who had diagnoses including Parkinson's disease, dementia, and muscle weakness, was assessed as being at risk for elopement. The care plan for this resident included interventions such as engaging in purposeful activity, identifying triggers and patterns for wandering, and ensuring close monitoring in common areas or during activities. Additionally, a wander guard bracelet was ordered and was to be checked for placement every shift. On the day of the incident, the resident was served dinner in the hallway and was left unsupervised while the CNA distributed dinner trays to other residents. The CNA did not maintain visual confirmation of the resident's location and did not inform other staff that she would be unable to monitor the resident directly. At some point, the resident left the facility through an unknown door, and the wander guard alarm did not alert staff to the resident's exit. The absence of an alarm and lack of direct supervision allowed the resident to leave the premises undetected. The resident was found offsite by a member of the public, who contacted emergency services and the facility. The resident was subsequently returned to the facility. Interviews with staff, including the DON and ADM, confirmed that the wander guard system is a monitoring tool and does not prevent elopement, emphasizing that staff supervision and monitoring are essential. The facility's own policies and product documentation also indicated that close personal surveillance is necessary in addition to monitoring equipment.