Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including dementia and an unsteady gait exited the facility undetected by staff. The resident had a documented history of elopement risk, as indicated in the care plan and elopement risk assessment, which included interventions such as placing a photograph on a wander list, using a pink armband, and redirecting attention away from exit areas. On the day of the incident, the resident participated in a bingo activity and was left waiting to be transported back to their room. Staff later discovered the resident's wheelchair empty and initiated a search, but the resident was not found within the facility. The facility's timeline and staff interviews revealed that there was a delay in recognizing the resident's absence and activating the Code Pink alert. Staff checked the resident's room and surrounding areas before initiating a facility-wide search. The security officer on duty did not observe the resident leaving, as attention was divided between managing gate access for a transport van and a visitor. The resident was able to exit the facility and travel approximately 0.7 miles away, eventually being found by law enforcement wandering in a high-traffic neighborhood. Record reviews and staff interviews confirmed that the resident was at high risk for elopement and that staff were aware of this risk. Despite existing policies and care plan interventions, the resident was able to leave the facility without detection, indicating a failure to provide adequate supervision and a secure environment. The incident resulted in the resident being exposed to significant environmental hazards before being located and returned to the facility.