Failure to Prevent Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
The facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for two residents. One resident, who had multiple diagnoses including severe dementia, altered mental status, and was identified as an elopement risk, was found missing after staff discovered the resident's wander guard device had been removed and left on the bed. The resident was later located at a hospital after being found wandering in the community. The care plan for this resident had previously identified the risk and implemented a wander guard device, but the device was not effective in preventing the elopement. Another resident, with diagnoses including toxic encephalopathy and schizophrenia, was assessed as low risk for elopement and was cognitively intact. This resident was observed moving around the facility and was later found missing from their room, with all personal belongings gone. Staff discovered the absence during routine checks, and the resident returned to the facility the following day. Interviews and video surveillance revealed that both residents exited through the same south door in the main lobby, which is left open and unalarmed for several hours daily and is not monitored during certain periods, contributing to the residents' ability to leave the facility unsupervised.