Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to follow its protocol and policy to prevent the elopement of a cognitively impaired resident. The resident, who had diagnoses including hypertension, altered mental status, and vascular dementia, was assessed with a Brief Interview of Mental Status (BIMS) score of 4 out of 15, indicating moderate cognitive impairment. On the day of the incident, the resident was last observed by staff sitting in a chair in their room at approximately 6:00 PM. At around 7:15 PM, staff were notified by a family member that the resident had returned home, prompting staff to search the facility and confirm the resident was missing. Further investigation revealed that the resident exited the facility through the rear entrance when a family member entering the building held the door open, allowing the resident to leave unsupervised. The resident subsequently arranged their own transportation home and, upon arrival, sought a spare key from a neighbor to enter their residence. The facility's policy defined elopement as a cognitively impaired resident leaving the facility grounds unattended and without staff knowledge, which was not adhered to in this instance.