Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a diagnosis of Alzheimer's Disease and a BIMS score indicating severe cognitive impairment was identified as being at risk for wandering, with a care plan in place that included a wander guard. Despite these measures, the resident was able to exit the facility unsupervised. On the day of the incident, the resident was last seen by a charge nurse in their room. Later, a GNA arriving for her shift heard a soft alarm, which she initially mistook for a call light. Upon investigation with an LPN, they discovered an exit door slightly open and another door leading outside that was unlocked, with the alarm still sounding faintly. After realizing the resident was missing, staff initiated a head count and notified the RN supervisor, who activated the facility's missing resident protocol. The facility conducted a search of the building and surrounding neighborhood, and local law enforcement was called to assist. The resident's family was notified, and the search continued into the evening with the involvement of police and specialized search equipment. The resident was eventually found the next morning in a wooded area near the facility by a staff member. The investigation revealed that the resident was able to leave through an exit door due to a very low-volume alarm that was barely audible from the nursing station. The resident had not previously eloped. The incident highlighted a failure to prevent a resident at risk for wandering from exiting the facility unsupervised, as well as issues with the effectiveness and audibility of the door alarm system at the time of the event.