Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
A deficiency occurred when a resident with a documented history of dementia, muscle weakness, and generalized anxiety disorder exited the facility unescorted. The resident, who had severe cognitive impairment and required supervision with daily activities, was admitted without a wander guard and was assigned a room on the first floor. The resident was able to leave the facility through the front doors after being buzzed out by the Receptionist, who did not recognize the individual as a resident and mistook them for a visitor. The facility's elopement risk assessment, completed at admission, did not identify the resident as a wander or elopement risk, despite family reports of wandering and aggressive behavior prior to admission. The resident was not included on the elopement risk list at the front desk, did not have an identification band, and was not known to the Receptionist as a new resident. The Receptionist allowed the resident to exit the building without verifying their identity, and the absence of a wander guard or other alert system contributed to the resident's ability to leave unnoticed. The resident was discovered missing during staff rounds, prompting a search of the facility. The resident was later located by emergency medical services after entering a neighboring home and was transported to the hospital for evaluation. The incident revealed gaps in the facility's supervision, risk assessment, and communication processes, which allowed the resident to exit the facility without appropriate safeguards in place.