Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure a safe environment for a resident with a known history of wandering and elopement risk. The resident, who had diagnoses including dementia, hypertension, and heart failure, had previously demonstrated exit-seeking behaviors, including verbal aggression, threats to leave, and attempts to exit through windows and doors. Despite being identified as at risk for elopement and having multiple care plan interventions in place, the resident was able to leave the facility by following a food delivery person out the front entrance. The resident was missing for approximately one hour before being located by police in a nearby field and returned to the facility. Documentation showed that the resident had a history of wandering, including incidents where the resident attempted to leave through windows and was found at exit doors. The resident's care plan included interventions such as disguising exits, using a wanderguard, frequent observation, and diversional activities. However, on the day of the incident, the resident was able to elope using a walker that did not have a wanderguard, as opposed to their wheelchair which was equipped with one. The facility's failure to ensure all necessary elopement prevention measures were in place and to provide adequate supervision directly led to the resident's unsupervised exit from the property.