Failure to Supervise and Monitor Resident with Elopement Risk
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for a resident with a known history of dementia and wandering, resulting in an elopement incident. The resident had multiple documented episodes of confusion, wandering, and exit-seeking behaviors, including looking for her car and attempting to leave the facility. Despite these behaviors, the facility did not reassess the resident's risk for elopement or update her care plan to include individualized interventions to prevent wandering and elopement. The initial care conference did not address the resident's wandering, and staff failed to recognize and respond to the resident's escalating risk. On the day of the incident, the resident exited the facility using her wheeled walker and was later found off campus by a bystander, who notified the facility. The facility's policy required evaluation of residents' potential for wandering upon admission and as needed, but there was no documentation of a reassessment or implementation of additional interventions after the resident began exhibiting wandering and exit-seeking behaviors. The lack of timely identification and response to the resident's risk for elopement placed all residents at risk for similar incidents.