Elopement Due to Inadequate Supervision and Exit Monitoring
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, moderate cognitive impairment, and a history of wandering was able to elope from the facility. The resident's care plan identified him as being at risk for elopement, required the use of a Wanderguard bracelet, and instructed staff to check its placement and functionality regularly. The care plan also noted that the resident would often wait by the facility entrance for his wife and required redirection and supervision. Despite these interventions, the resident was able to exit the facility by following a visitor out the main entrance before the door's lock could engage. The Wanderguard alarm system was triggered, and staff found the resident outside the main entry, leaning against a brick wall. The resident was assessed and found to have no injuries before being redirected back inside. Interviews with staff confirmed that the resident's Wanderguard was checked each shift and that he was known to be confused and required supervision when outside. The facility's policy required close monitoring of residents at risk for elopement and adherence to individualized care interventions, but the resident was able to leave the building unsupervised due to a lapse in monitoring at the entrance.