Failure to Investigate and Prevent Resident Elopement
Penalty
Summary
A resident with a history of elopement and severely impaired cognition due to Alzheimer's disease was identified as an elopement risk upon admission. The resident was ambulatory without a device and had previously wandered from home. Despite being assessed as an elopement risk and fitted with a secure care device, the resident was able to leave the facility and was found at a nearby hospital's helipad. Documentation indicated that the secure care device should have prevented exit, but there was no immediate investigation into how the resident was able to leave undetected. There was a lack of timely and thorough investigation following the elopement incident. Documentation of required 15-minute checks was missing, and there was no evidence of staff education or changes in interventions immediately after the event. Staff statements and investigation into the door alarm and secure care system were not completed until two days after the incident. Additionally, there was no documentation of secure care checks on the exit door or evidence that all staff were educated on responding to door alarms in the immediate aftermath.