Failure to Prevent Elopement Due to Unsecured Door and Lack of Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a high risk for elopement was able to exit the facility without staff knowledge or supervision. The resident, who had dementia with psychotic disturbances, hallucinations, delusions, and a documented history of wandering, was admitted from a private residence where she had previously exhibited exit-seeking behaviors. Upon admission, assessments identified her as high risk for elopement, but her initial care plan did not include interventions to address this risk. On the day of the incident, the resident exited through an unlocked and unalarmed front door. The door, which was typically secured, had its lock override implemented, leaving it unsecured and the alarm disabled. Staff were unaware that the door was left in this state, and the resident was able to leave the building. The resident was later found by an off-duty staff member walking outside, approximately two blocks away from the facility, and was returned without injury. At the time of the incident, the resident was not wearing her WanderGuard device, as she had removed it from her wrist and staff had not noticed its absence. Interviews and documentation revealed that staff were not consistently checking for the placement of the WanderGuard device prior to the incident, and the override code for the door was widely known among staff, contributing to the failure to secure the door. The facility's elopement risk policy required individualized care plans and secure alarmed doors for residents at risk, but these measures were not implemented for this resident prior to the elopement event.