Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A resident with severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, was assessed as being at risk for elopement and had a care plan in place for this risk. Despite these precautions, the resident was able to exit the facility without staff knowledge. The resident left their assigned area, traversed an unoccupied wing, and exited the building, ultimately being observed outside by staff and subsequently brought back inside. The resident was wearing a wander alert device, which was reported to be functioning at the time of the incident. Staff interviews revealed that the resident was known to wander and had a history of attempting to leave the facility, often expressing confusion and a desire to go home. On the day of the incident, it was believed that the resident followed a contracted dietary worker out of a secured area while staff were preparing to serve breakfast. The dietary worker did not notice the resident following him and was not aware of the resident's status or risk. Multiple staff members confirmed that alarms on exit doors were sounding, but the resident was still able to leave the building unnoticed for a period of time. The incident was discovered when a nurse saw the resident outside through a window and alerted other staff, who then retrieved the resident. Staff interviews indicated that there was a lack of awareness regarding the resident's whereabouts, and some staff were unsure when or how the resident left the unit. The facility's policy defined elopement as a resident leaving a secured area or the building alone and unwitnessed by staff, which occurred in this case.