Resident Elopement Due to Inadequate Supervision and Window Security
Penalty
Summary
A deficiency occurred when a resident with a history of confusion, impaired safety awareness, and wandering behaviors was able to elope from the facility by climbing out of a window in their room. The resident had previously demonstrated goal-directed and aimless wandering, had been found attempting to leave the facility, and was identified as being at risk for elopement. Despite these behaviors, the resident was able to remove the window screen and disengage the safety latch without staff awareness, as the windows were not equipped with alarms to alert staff to unauthorized exits. On the day of the incident, the resident was noted to be fixated on leaving the facility to pay taxes and required repeated redirection by staff. The resident was last seen in their room after being assisted with bathing and toileting, and shortly thereafter, was observed outside the facility by staff and members of the public. The resident crossed a parking lot and a busy roadway, and was missing for approximately seven minutes before being located by staff and law enforcement. The resident was combative and refused to return to the facility, ultimately being transported to the hospital for evaluation. Interviews with staff confirmed that the resident had a Wander guard device, but there was no order for regular checks of its placement and function. The care plan indicated the need for the Wander guard to be on at all times, but the lack of window alarms and the resident's physical ability to exit through the window without detection contributed to the elopement. The facility's investigation identified the disengaged window safety latch as the means of exit and noted the absence of an alarm system on the windows as a critical factor in the incident.