Elopement Due to Inadequate Supervision and Window Security
Penalty
Summary
A resident with a diagnosis of unspecified dementia and a BIMS score of 3, indicating severe cognitive impairment, eloped from a locked unit within the facility. The incident report indicated that the resident left the facility through a window and was returned by local law enforcement. The facility's investigation did not document how far the resident traveled after leaving or the exact time frame during which the resident was missing. At the time of the incident, the resident was not accounted for during a routine check, and the facility initiated a search and notified police. Record review showed that the facility did not have adequate measures in place to prevent the resident from leaving through a window, as the window mechanisms allowed for partial opening and could be tampered with from inside. Maintenance logs and resident records were reviewed, but there was no indication that daily checks on windows in the locked unit or weekly checks in the rest of the building were sufficient to prevent such an incident. The resident, when interviewed, could not recall how they exited the building or how far they traveled before being found.