Failure to Provide Appropriate Supervision and Services for Resident with Dementia Resulting in Elopement
Penalty
Summary
A resident with a diagnosis of dementia, psychotic disturbance, gait abnormalities, and anxiety was housed in a secured, locked unit designed to prevent elopement. Despite being identified as at risk for elopement and having a care plan that included interventions such as distraction, structured activities, and reorientation strategies, the resident was able to leave the unit unsupervised. Facility documentation and camera footage revealed that the resident wandered aimlessly in the unit while three agency nurse aides, unfamiliar with the resident and the unit, were sitting in the common area with limited interaction and one using a cell phone. The resident ultimately exited the facility through a back door, which required a staff code to open and did not trigger an alarm, likely by following a staff member who opened the door. The resident was found by local police at a neighbor's house and returned to the facility after being out for approximately 30 minutes. The facility's investigation confirmed that all staff on duty during the incident were new agency staff who lacked prior knowledge of the resident and the unit. The care plan interventions for supervision and redirection were not implemented, as staff failed to provide appropriate monitoring and engagement. The facility's policy required staff to prevent elopement and maintain resident safety, but these measures were not followed, resulting in the resident's unsupervised exit from the secured unit.