Failure to Implement Timely Elopement Prevention Measures for At-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement preventative measures to reduce the risk of elopement for a resident with dementia and a history of falls. The resident was admitted with diagnoses including dementia and had previously attempted to leave the facility. On one occasion, the resident left the facility without notifying staff and was later found at a hospital. Documentation showed that the care plan identified the risk of elopement and set a goal for the resident not to leave without an escort, but interventions listed were limited to encouraging participation in activities and personalizing the resident's room. Despite the resident's known risk and a documented incident of elopement, there were no immediate interventions such as a wander guard device or 1:1 supervision implemented after the first elopement. Staff interviews confirmed that a wander guard device was not ordered or placed until after a second elopement occurred. The DON acknowledged that no interventions were in place to prevent the resident from leaving unattended following the initial incident, contrary to facility policy requiring systematic monitoring and management of residents at risk for elopement.