Elopement Due to Inadequate Supervision and Visitor Error
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of wandering was not adequately supervised, resulting in the resident eloping from the facility. The resident, who had diagnoses including unspecified dementia, hypertension, insomnia, mood disorder, and hyperlipidemia, was independently ambulatory with a walker and had a wander guard in place. Surveillance footage showed the resident left the facility at 7:00 p.m. and was found by police approximately 0.5 miles away after a civilian reported the individual. The resident was returned to the facility without injury. Prior to the elopement, the resident was last seen by an LVN in front of the nurse's station around 6:30-6:40 p.m. The LVN redirected the resident to the common area but then became occupied with other tasks, during which time the resident left the area. The facility's secured unit was not open at the time of the incident. The elopement was facilitated when a visitor, unaware that the individual was a resident, opened the door for the resident and allowed them to exit the building. The facility's policies required immediate search and assessment if a resident could not be located or if alarms sounded, and staff were responsible for maintaining resident safety at all times. However, the combination of insufficient supervision, lack of secured unit access, and a visitor inadvertently assisting the resident in leaving led to the resident's unsupervised exit from the facility.