Failure to Prevent Elopement of High-Risk Resident Due to Lack of Effective Safety Measures
Penalty
Summary
The facility failed to implement interventions, supervision, and effective safety measures to prevent the elopement of a resident who was identified as being at high risk for elopement and exhibited ongoing exit-seeking behaviors. The resident had a history of alcohol-induced persisting dementia and Alzheimer's disease, and was admitted to the facility following a hospital stay where elopement precautions, including a sitter, were required. Upon admission, the resident was assessed as high risk for elopement, with care plan interventions suggested, but documentation shows repeated episodes of exit-seeking, agitation, and attempts to leave the facility, with staff redirection efforts proving ineffective. Despite the resident's documented behaviors and high-risk status, the facility did not implement electronic monitoring devices or other effective interventions to prevent elopement. The resident ultimately exited the locked unit by following or being let out by a visitor or staff member who entered the exit code, as the facility allowed visitors to know and use the exit codes independently. The front lobby doors were not locked from the inside, and the area was not routinely monitored, especially after hours when administrative staff were not present and the receptionist position was vacant. The resident was missing for approximately 17.5 hours before being found by emergency personnel with injuries to the forehead. The investigation revealed that no alarms sounded and nothing alerted staff to the resident's exit. The facility had discontinued the use of electronic monitoring devices (wanderguards) for residents on the locked unit, despite multiple residents being identified as at risk for elopement. Sixteen additional residents were also identified as being at risk for elopement, placing them in an immediate jeopardy situation due to the lack of effective safety measures and supervision.