Failure to Prevent Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
A cognitively impaired resident with a history of dementia, Alzheimer's disease, schizophrenia, and agitation, who was identified as being at risk for elopement, was able to exit the facility without staff knowledge. The resident independently entered a door keypad code to unlock an exit door and left the building. The code had been overheard by the resident, and there was no documentation of when door codes were changed or how access to the codes was controlled. The resident was outside for an unknown period before returning to the building after ringing the front doorbell and being let in by a staff member. The resident's care plan and risk assessments indicated fluctuating levels of elopement risk, with interventions such as window alarms, AirTags in shoes, and previous use of a wearable tech device, which the resident refused to use. Despite being identified as high risk for elopement, the facility did not ensure that environmental controls, such as secure door codes and effective monitoring, were in place to prevent the resident from leaving unsupervised. Staff interviews revealed a lack of routine elopement drills, inconsistent documentation of code changes, and absence of a photo book or other identification system for at-risk residents at the reception desk. Facility policy required regular elopement risk assessments, implementation of risk reduction strategies, and environmental controls, including secure door codes and monitoring systems. However, the policy was not consistently followed, as confirmed by the administrator. There were no cameras to verify the resident's exit, and staff and administration were uncertain about the frequency of code changes and the dates of previous elopements. The failure to maintain secure access controls and provide adequate supervision allowed the resident to elope undetected.