Failure to Prevent Resident Elopement and Incomplete Investigation
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision to prevent a resident with dementia, delirium, insomnia, depression, and auditory hallucinations from leaving the facility unsupervised. The resident, identified as an elopement risk and wearing a wander guard, was able to exit the building through a dining room window during the early morning hours. Staff discovered the resident missing during routine checks and later found her outside in a parking lot adjacent to the facility. The window used for the exit was found to be easily opened and the screen could be removed without difficulty, as confirmed by the facility administrator and maintenance director. The care plan for the resident included interventions such as distraction, structured activities, one-to-one talks, walking the halls, and the use of a wander alert device. Despite these measures, the resident was able to leave the facility undetected, and no alarms were triggered. The resident had a documented history of wandering, exit-seeking, and expressing a desire to return home. Staff interviews confirmed that the resident was frequently observed packing her belongings and attempting to leave, and that she was often awake and wandering at night. The facility's investigation into the incident was incomplete. Only two LPNs provided witness statements, and no interviews or statements were obtained from other staff present during the incident, including several CNAs who were on duty. The investigation lacked specific details such as the last time the resident was seen, how she was found, and which staff were involved. There was also no assessment of the window used for elopement or of other windows in the facility, and no evidence of new interventions to prevent similar incidents. The facility's policy required a thorough investigation and timely reporting, which was not followed in this case.