Failure to Supervise Cognitively Impaired Resident Results in Elopement
Penalty
Summary
A cognitively impaired resident with a history of elopement and a severely impaired BIMS score was identified as being at risk for wandering and elopement. The resident's care plan included interventions requiring staff to accompany them to meals and scheduled activities. Despite these interventions, the resident was allowed to leave the unit unescorted in their wheelchair after an LPN deactivated the elevator's wander guard system, permitting the resident to travel alone to the lobby. Upon arrival in the lobby, the resident approached the rear exit door, which was equipped with a wander guard alarm. The receptionist at the desk disengaged the alarm, allowing the resident to exit the facility through the rear door. Video footage confirmed that the resident left the building unaccompanied and was last seen on camera propelling their wheelchair through the parking lot and out of view. Staff did not notice the resident's absence until a dinner tray was found untouched during rounds several hours later. The facility's failure to provide adequate supervision and to follow the care plan interventions for a resident at high risk for elopement resulted in the resident leaving the premises unsupervised. The resident was not located until several hours later, when they were found in a nearby town and returned to the facility. The incident occurred despite the wander guard system being operational and no equipment malfunctions being reported.