Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to implement and ensure effective and efficient preventative measures to prevent the neglect and elopement of a resident who was identified as high risk for elopement due to a diagnosis of dementia and a history of wandering. The resident's care plan included interventions such as placing a photograph on a wander list, redirecting attention away from exit areas, assisting with meaningful activities, and alerting staff to monitor the resident's location. Despite these interventions, the resident was left unsupervised after an activity, and staff did not maintain the assigned level of supervision. On the day of the incident, the resident participated in a Bingo activity that concluded at 4:00 PM. The resident was waiting to be transported back to their room, but when staff arrived, only the resident's empty wheelchair was found. Staff searched the surrounding areas and the resident's room before activating a Code Pink at 4:45 PM. The facility is located in a high-traffic area, increasing the risk associated with elopement. The resident was able to exit the facility undetected through an electronic gate at the front of the building. The security officer on duty was distracted by managing both an outgoing transport van and an incoming visitor, resulting in both gates being open simultaneously and a lapse in monitoring the exit. The resident was later found in a nearby residential neighborhood and transported to a local hospital for evaluation. Interviews with staff revealed gaps in supervision and communication, as well as a lack of adherence to established protocols for monitoring high-risk residents. The facility's failure to ensure that residents were not able to leave the premises and to implement the assigned level of supervision directly contributed to the resident's elopement and placed the resident at risk for harm.