Failure to Prevent Elopement for Resident with Dementia
Penalty
Summary
The facility failed to provide the highest practicable care regarding elopement prevention for a resident with severe cognitive impairment and a known history of wandering and exit-seeking behaviors. The resident, diagnosed with dementia and assessed as an elopement risk, was moved from a locked memory care unit to another nursing unit. Despite care plans and physician orders requiring staff to check the resident's wander guard placement every shift, documentation and staff interviews revealed lapses in monitoring and intervention. The resident exhibited multiple episodes of exit-seeking, including attempts to leave the facility and being found at the main entrance on several occasions. On one occasion, a new dietary aide exited the building, followed by the resident, who stated he was going to the police station. The aide, unsure of protocol, asked a visitor to watch the resident while she sought help. By the time staff responded, the resident had left the parking lot and was found walking down the road, requiring several staff members to return him to the facility. It was noted that the resident did not have a wander guard on at the time of the incident, despite orders for its use and regular checks. These failures to follow established policies and care plans resulted in the resident's elopement and demonstrated a lack of adequate supervision and monitoring.