Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure the safety and adequate supervision of a resident identified as being at high risk for elopement. The resident, who had severe cognitive impairment, vascular dementia, a history of wandering, and was ambulatory, was last seen on the unit by staff before the front door wander guard alarm was triggered. After the alarm sounded, a CNA responded, checked the immediate area outside the front door and parking lot, but did not see anyone and returned to the facility, shutting off the alarm. Staff were then notified and a facility-wide search was initiated. The resident was eventually found by an RN walking approximately two-tenths of a mile from the facility, having left without staff knowledge. The resident's medical record indicated a history of wandering and a high risk for elopement, with care plan interventions in place, including the use of a wander guard device and regular checks to ensure its functionality. Despite these interventions, the resident was able to exit the facility undetected and was not immediately located after the alarm was triggered. The incident was reported to the DON, administrator, and tribal police, and the resident was returned safely to the facility. The failure to provide adequate supervision and respond effectively to the elopement risk resulted in the resident leaving the facility unsupervised.