Resident Elopement Due to Inadequate Supervision and Wander Guard Removal
Penalty
Summary
A resident with a high Brief Interview for Mental Status (BIMS) score of 13, who was assessed as being at risk for elopement and wandering, was able to remove her wander guard by cutting it off with scissors obtained from another resident. The resident then exited the facility through the main doors without staff knowledge and was later found by local law enforcement in a park across the street. The incident report indicated that staff were not aware of the resident's absence until notified by police, at which point the resident had been missing for approximately 45 minutes. Review of facility documentation showed that the resident's most recent Minimum Data Set (MDS) did not indicate she was wearing a wander guard, despite a prior risk assessment identifying her as at risk for elopement. Staff interviews revealed that the resident was new to the facility, enjoyed social activities, and was generally supervised through hourly rounds and 15-minute checks following the incident. The facility's monitoring and supervision failed to prevent the resident from obtaining scissors, removing her wander guard, and leaving the premises undetected.