Failure to Prevent Elopement of High-Risk Resident from Secured Unit
Penalty
Summary
A resident with a history of dementia, unsteadiness, and high elopement risk was admitted to the facility and placed in the memory care unit due to previous attempts to leave unattended and poor safety awareness. The resident's care plan identified elopement risk and included interventions such as placement in a secured unit and providing diversions. Despite these measures, the resident was able to exit the facility undetected. On the morning of the incident, the resident was last seen asleep in his room by staff. Later, staff discovered the resident missing and initiated a search. It was determined that the resident had escaped through a window in the dining area of the memory care unit, which was found broken with the screen pushed out. The resident's walker was left by a table, and he was later located approximately a mile away from the facility. Interviews with staff confirmed that the resident was not observed leaving, and the escape was not detected until a routine check revealed his absence. The resident later explained that he had loosened screws on the window to facilitate his escape and used a chair in the backyard to climb over the fence. The resident reported being bored and wanting to socialize, and also mentioned seeking cigarettes as a motivation for leaving. Staff interviews indicated that the resident had previously shown stress when out of cigarettes, and that the facility was aware of his high risk for elopement. The deficiency occurred due to the failure to provide adequate supervision and maintain an environment free from accident hazards, allowing the resident to exit the secured unit undetected.