Failure to Supervise Cognitively Impaired Resident Results in Elopement
Penalty
Summary
A cognitively impaired ambulatory resident with a history of dementia, severe cognitive impairment, and previous elopement attempts was not adequately supervised, resulting in the resident exiting the facility unsupervised. The resident's care plan and assessments documented significant elopement risk, including recent behaviors of exit seeking, packing belongings, and expressing intent to leave. Despite these documented risks and recent incidents of exit-seeking behavior, the resident was able to leave the facility early in the morning, triggering a door alarm. A Licensed Practical Nurse (LPN) responded to the alarm and followed the resident outside, attempting to redirect her back to the facility. The resident was agitated, refused redirection, and continued walking through public areas, including crossing a main highway. The LPN continued to follow but lost sight of the resident in a local business parking lot while attempting to seek assistance. Surveillance footage and witness interviews confirmed that the LPN was separated from the resident, who then left the area unsupervised for over two hours until located by police in a nearby garage. Interviews with staff revealed gaps in knowledge regarding elopement risk assessments, inconsistent communication about the resident's behaviors, and uncertainty about staff responsibilities during elopement incidents. Several staff members did not hear the door alarm, and some were unaware of the resident's elopement risk or recent exit-seeking behaviors. The failure to provide continuous supervision and maintain line of sight with the resident, despite clear documentation of elopement risk, directly led to the resident's unsupervised absence from the facility.