Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses of dementia and delirium exited the facility without staff knowledge. The resident, who had a history of wandering and was assessed as being at risk for elopement, was wearing a wanderguard device intended to lock doors and sound an alarm when a resident at risk approaches an exit. On the day of the incident, the resident left the rehab unit, which was not a secured unit but had a door equipped with a wanderguard alarm and keypad. However, the door did not lock or alarm as intended when the resident approached, allowing her to exit. The resident then proceeded to another set of sliding glass doors, which did not have a wanderguard alarm, and exited the building. She was found by staff on a sidewalk near the employee parking lot, approximately 150 feet from the building. Interviews and record reviews confirmed that the resident had previously displayed exit-seeking behaviors and was disoriented to place, with poor safety awareness. The care plan identified her as being at risk for wandering and elopement, and she had previously attempted to follow family members out of the facility. Despite these known risks and interventions in place, the failure of the wanderguard system and lack of alarms on the sliding doors allowed the resident to leave the facility unsupervised.