Failure to Prevent Unsafe Wandering and Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to provide adequate supervision and implement care-planned interventions to prevent unsafe wandering and elopement for cognitively impaired residents. One resident with a diagnosis of Alzheimer's disease and severe cognitive impairment was not identified as an elopement risk and was not wearing a wander alert bracelet. This resident was able to leave the facility unsupervised and was later found in a hospital parking lot. Staff interviews revealed that the resident was last seen shortly before the incident, and it was discovered that a family member of another resident had access to a door code, which may have allowed the resident to exit the building undetected. The facility's policy did not permit family members to have door codes, and there was no documentation that the resident was at risk for elopement prior to the incident. Additionally, the facility failed to ensure that another resident identified as an elopement risk was wearing a wander alert bracelet as care planned. Observation and record review showed that this resident did not have the bracelet on, and there was no documentation verifying its placement or function. Staff interviews confirmed that daily checks and documentation of wander alert bracelets were not consistently performed, and a documentation box for this intervention had been missing from the Treatment Administration Records for an undetermined period. These failures resulted in a lack of adequate supervision and monitoring for residents at risk for elopement.