Failure to Prevent Elopement Due to Inadequate Supervision and Unalarmed Exits
Penalty
Summary
A resident with severe impairment in daily decision-making skills and a diagnosis of dementia was not provided adequate supervision to prevent elopement. The resident had a history of confusion and wandering into other residents' rooms, as documented in nurse's notes and care plans. Although the care plan identified the risk for elopement and included the use of a wander guard device, it did not specify the frequency of monitoring required. The resident was able to exit the facility undetected, as the wander guard alarm did not sound due to the absence of alarms on certain exit doors along the resident's path. The resident was missing for over 15 minutes and was later found outside the facility with injuries, including a bump on the forehead, an abrasion on the knee, and a bruise on the elbow. Interviews and facility review revealed that several exit doors were not alarmed, and staff were not aware of which residents were confused or at risk for elopement. The Director of Nurses stated that more frequent monitoring was not implemented until after the elopement incident, as the resident had not previously attempted to leave. The facility's elopement policy did not provide guidance on preventive measures, and response times to alarms were observed to be delayed. The lack of adequate supervision and failure to ensure all exits were secured contributed to the resident's ability to elope and sustain injuries.