Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and accident hazard prevention for a resident assessed as an elopement risk. The resident, who had impaired cognitive function, restlessness, agitation, and a traumatic brain injury, was identified as an elopement risk upon admission and was fitted with a Wander Guard device. However, the resident's care plan did not include interventions related to wandering or supervision. The resident was able to remove a window and screen in an empty room under maintenance, exit the building undetected, and was later found on an adjacent property after having fallen and sustaining scrapes to both knees and complaining of head and knee pain. The Wander Guard did not alarm because the window was not equipped with an alarm system. Interviews with staff confirmed that the resident was last seen over an hour before being found and that the Wander Guard was still in place when the resident was located. The Director of Nursing acknowledged that the window used for the exit was not alarmed, and the resident was able to leave without staff noticing. Additionally, during an observation, the same resident was seen exiting through an alarmed door while staff were preoccupied assisting another resident, and no intervention or redirection was provided by the employee present.