Resident Elopement Due to Failure in Supervision and Safety Protocols
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, including vascular dementia and Alzheimer's disease, was able to elope from the facility without staff knowledge for nearly seven hours. The resident had a history of wandering, as indicated by her previous facility and her Minimum Data Set (MDS) assessment, which showed a BIMS score of 1 out of 15 and recent wandering behavior. Despite this, the resident was not provided with a wander guard upon admission, and staff failed to implement appropriate supervision or monitoring measures. The sequence of events leading to the deficiency began with the resident's admission, during which the need for a wander guard was communicated to staff and documented in the electronic medical record (EMR) dashboard. However, the assigned nurse did not apply the wander guard, and there was a lack of communication between staff regarding the resident's supervision needs. Video surveillance showed that the wander guard was handled but not applied, and the nurse going on break did not relay any special supervision instructions. Later, a registered nurse opened the facility door and allowed the resident to exit, not recognizing her as a resident. The resident was able to leave the facility and was later found at a nearby hospital, which contacted the facility. Staff interviews revealed gaps in training and procedures for identifying residents versus visitors, as well as failures in following established protocols for new admissions at risk for elopement. The facility's policy required assessment and intervention for elopement risk, but these were not properly executed, resulting in the resident's unsupervised exit.