Failure to Prevent Elopement in High-Risk Resident with Dementia
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with dementia and a high risk for elopement from leaving the premises unsupervised and undetected. The resident, who was admitted with a diagnosis of dementia and assessed as having no cognitive understanding, had a documented high risk for wandering and elopement. The care plan identified the resident as being at risk for elopement due to dementia. Despite these assessments, the resident began exhibiting exit-seeking behaviors several days prior to the incident, which was noted by staff. On the day of the incident, the resident was last seen in their room by the DON, but was later found missing and subsequently located by the police after being gone for 45 minutes. Staff interviews confirmed awareness of the resident's exit-seeking behavior and high elopement risk, but increased supervision was not implemented. Facility policy required identification and intervention for residents at risk of unsafe wandering, but these measures were not effectively carried out for this resident.