Failure to Prevent Elopement Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known risk for elopement was left unsupervised and unattended in an unsecured area of the facility. The resident, who had diagnoses including dementia with behavioral disturbances, Wernicke's encephalopathy, and amnesia, required 15-minute checks due to his elopement risk. On the day of the incident, the resident was taken by a CNA to a church service held in the assisted living (AL) side of the facility, which did not have a wanderguard system on its exterior doors. The CNA left the resident in the AL dining room and returned to her assigned area, assuming the activities aide would assist the resident back. The activities aide, however, was not aware of the resident's presence or his need for supervision at that time. The facility's layout allowed residents from the long-term care (LTC) side, which was equipped with wanderguard systems, to access the AL side, where such systems were absent. Once the resident was on the AL side, there were no electronic safeguards to prevent him from exiting the building. Staff interviews confirmed that the last wanderguard alarm was turned off to allow the resident into the AL area, and after that point, there was no further monitoring or alarm system in place. Documentation revealed that 15-minute checks were not completed for the resident from 10:15 a.m. to 1:00 p.m., and staff did not notice the resident was missing until after the church service had ended and a search was initiated. The resident was able to exit the facility through an unsecured door on the AL side and was found approximately three blocks away by staff after an extended search involving facility staff, family, and local police. At the time of the incident, the resident's care plan included interventions such as monitoring his location every 15 minutes, use of a wanderguard, and documentation of wandering behavior, but these interventions were not followed during the period in question. The failure to provide adequate supervision and maintain a secure environment directly led to the resident's elopement.