Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses of dementia and an unsteady gait, identified as high risk for elopement, was able to leave the facility undetected by staff. The resident had a documented care plan indicating elopement risk, including interventions such as placement on a wander list, use of a pink armband, and staff monitoring. On the day of the incident, the resident participated in a bingo activity and was left waiting in a wheelchair after the activity concluded. Staff discovered the wheelchair empty and, after searching the immediate area and the resident's room, activated a Code Pink to report the missing resident. Despite the facility's policies and procedures for elopement prevention and accident hazard reduction, the monitoring and supervision provided were insufficient. Staff interviews revealed that although multiple staff members were present during the activity and responsible for transporting residents back to their rooms, the resident was able to leave the area without being noticed. Security procedures at the facility gate were also inadequate, as the security officer was distracted by managing both incoming and outgoing traffic, allowing the resident to exit the premises without detection. The resident was found by law enforcement approximately 0.7 miles from the facility, wandering in a high-traffic neighborhood, and was subsequently transported to a hospital for evaluation. The incident demonstrated a failure to provide a secure environment and adequate supervision for a resident at known risk for elopement, as required by facility policy and regulatory standards. The lack of effective monitoring and communication among staff contributed to the resident's unauthorized departure and delayed response in locating the individual.