Failure to Prevent Elopement During Power Outage
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with Alzheimer's disease and a seizure disorder who had a documented history of wandering behaviors. The resident was identified as being at risk for elopement through an evaluation and was ordered a security bracelet to alert staff when approaching monitored doors. The care plan specifically addressed the risk for elopement due to the resident's diagnosis and history. Progress notes documented repeated incidents of the resident testing door handles, keypads, and attempting to open windows, as well as sprinting toward open doors when noticed. During a scheduled facility power outage, the magnetic locks on the stairwell doors became disengaged, allowing the resident to leave the locked unit and access another floor via the stairwell. Security staff observed the resident on CCTV, and the nursing supervisor was notified and returned the resident to the unit. The resident did not sustain any injury or show signs of emotional distress. Staff interviews confirmed that the facility did not provide adequate supervision to prevent the elopement incident.