Failure to Prevent Elopement of Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment and a known history of wandering. The resident, who had diagnoses including Alzheimer's, dementia, difficulty walking, muscle weakness, heart failure, anxiety, acute kidney failure, and repeated falls, was identified as an elopement risk on their care plan. Despite this, the resident was able to exit the facility through a back door, reportedly following a construction worker, and was not immediately noticed as missing by staff. Staff interviews revealed that the resident was not present at dinner, and it was only after searching and being notified by construction workers that the absence was recognized. The resident managed to get approximately three blocks away before being located and returned to the facility. The facility's elopement policy required prompt reporting and intervention when a resident was suspected of leaving or missing, but staff failed to follow these procedures. There was confusion among staff regarding the resident's whereabouts, and the incident was not reported in a timely manner. Additionally, it was noted that during certain facility activities, such as fire drills or door testing, doors became unlocked, potentially contributing to the resident's ability to leave undetected. The director of nursing and other staff acknowledged that the resident was at risk for harm and that the elopement was preventable.