Failure to Prevent Elopement and Ensure Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision for a resident who was at risk for elopement. The resident, who had a history of traumatic brain injury, confusion, memory problems, impaired cognition, and lower leg impairment, did not speak or understand English and was not always understandable in her primary language. Despite these risk factors, the resident eloped from the facility twice during the night shift, each time wearing only a nightgown and without appropriate outerwear. On both occasions, the resident was found outside the facility, once in an apartment building and once near a shopping mall underpass, and was confused when found. Police were notified, and the resident was taken to a hospital after the second incident. Staff interviews and record reviews revealed that the Wanderguard alarm, intended to prevent elopement, was not checked for functionality, and staff were not properly oriented or trained in its use. The LVN assigned to the resident on the night of the first elopement stated they had never checked the Wanderguard alarm and had not received orientation. The facility's policy required evaluation for wandering risk, implementation of interventions, and regular checks of monitoring systems, but these procedures were not followed. The ADON could not explain how the resident exited the facility undetected, and there was a lack of consistent supervision at the front desk during the night shift.