Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a high risk for wandering was able to elope from the facility without staff knowledge or supervision. The resident, who had a BIMS score of 4 indicating severe cognitive impairment and diagnoses including Parkinson's Disease, depression, and unspecified dementia, had a documented history of exit-seeking behavior but had not previously left the building unsupervised. On the day of the incident, the resident exited the facility at approximately 6:15 p.m. and was outside for three to four minutes before staff responded to the door alarm and located him in front of the building. Observations and interviews revealed that the resident was independent in ambulation with a walker but displayed confusion and was unaware of how to use the call light for assistance. Staff interviews confirmed that the door alarms were functioning and that staff responded to the alarm after it sounded, but the resident was able to leave the building and walk a significant distance before being noticed. The resident was assessed upon return and found to have no harm or injury, and he had no recollection of the event. Review of facility records showed that the resident had been identified as high risk for wandering based on a wandering risk scale, and the facility had policies in place requiring prompt response to door alarms and interventions for residents at risk of elopement. However, at the time of the incident, the interventions in place were not sufficient to prevent the resident from leaving the building unsupervised, resulting in a failure to provide adequate supervision and prevent accidents as required.