Failure to Prevent Elopement and Ensure Resident Safety
Penalty
Summary
A resident with dementia, identified as being at risk for elopement and wandering, exited the facility through the front doors and left the property unsupervised. The resident was able to access a public road and was later found by police at a nearby apartment complex, having sustained a laceration to the forehead after a fall. The incident was reported to the State Survey Agency, and the resident required hospital evaluation and observation for the injuries sustained during the elopement. Facility records indicate that the resident had a history of wandering behaviors, including previous incidents where the resident attempted to leave the facility or triggered door alarms. The resident had been assessed as at risk for elopement and had a wander guard device placed. Despite these interventions, the resident was able to exit the facility undetected. On the day of the incident, a staff member responded to the front door alarm, briefly scanned the perimeter, but did not see any residents outside and did not conduct a head count as required by facility policy. Interviews with staff revealed gaps in training and adherence to elopement protocols. The staff member who responded to the alarm had not read the facility's elopement policy and was not fully oriented to the procedures. Facility policy required a full head count and further action if a resident could not be located, but these steps were not followed. Documentation and communication with law enforcement regarding the incident were incomplete at the time of the survey.