Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement an effective system to prevent cognitively impaired residents from leaving the premises without appropriate supervision. A resident with dementia, who had a documented history of wandering and elopement, was admitted to the facility and identified as a wanderer in both clinical documentation and the baseline care plan. However, the care plan did not specify interventions to monitor the resident, despite clear evidence of cognitive impairment and inability to make informed decisions as certified by two providers. On the day of the incident, the resident was able to exit the building unsupervised by following another resident's family member through an exit door at the end of a hallway. The resident traveled outside, down a steep hill to a parking lot near a public road and a large pond, and was found outside by housekeeping staff after being unsupervised for approximately 10 minutes. The lack of specific monitoring interventions and inadequate supervision directly contributed to the resident's ability to elope from the facility.