Failure to Assess and Supervise Elopement Risk Resulting in Resident Leaving Facility Unnoticed
Penalty
Summary
The facility failed to comprehensively assess and address the supervision needs and individualized interventions for a resident identified as an elopement risk. The resident, who had moderate dementia with behavioral disturbances, a history of delusional thinking, and was not safe to live independently, was admitted to the facility with clear documentation of cognitive impairment and safety concerns. Despite being identified as an elopement risk and having a Wanderguard device placed, there was no documented assessment or rationale for the use or changes of the Wanderguard, nor were there updates to the care plan or interventions following previous elopement attempts. On multiple occasions, the resident was able to leave the facility without staff knowledge. In one instance, the resident used a fingernail file to remove the Wanderguard and exited the building, later being found by a community member 12 blocks away, having crossed a major highway and railroad tracks. Staff interviews revealed inconsistent understanding of the resident's risk, lack of clear documentation of elopement incidents, and no comprehensive cognitive or safety assessments to determine the resident's ability to be unsupervised in the community. The facility did not complete incident reports, investigations, or care plan updates after these events, and family members were not notified of the elopements. Facility policy required a systemic approach to monitoring and managing residents at risk for elopement, including assessment, individualized care planning, and post-elopement procedures such as physical assessment, documentation, and family notification. However, these procedures were not followed, as evidenced by the lack of documentation, assessment, and communication after the resident's elopements. Staff interviews further indicated a lack of clarity regarding the resident's supervision needs and the purpose of the Wanderguard, contributing to the failure to prevent the resident from leaving the facility unsupervised.