Failure to Prevent Elopement of Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia with behavioral disturbance, anxiety disorder, and schizophrenia, eloped from the facility without supervision. The resident had a documented history of wandering, was assessed as being at risk for elopement, and had a care plan in place that included frequent monitoring, use of an elopement risk book, and exit alarms. Despite these interventions, the resident was able to leave the facility unsupervised. The incident took place when an LPN opened a secured side door to admit a recreational therapist. As the LPN walked away, the therapist held the door open, allowing the resident to exit the facility. The therapist was not aware that the individual was a resident and believed they were a family member. No staff member alerted the therapist to the resident's status or the need to prevent their exit. The resident was not noticed missing until later during a medication pass, prompting a facility-wide search and notification of the administrator, police, and family. The resident was eventually found off facility property by an acquaintance of the family and returned to the facility without evidence of physical injury. The facility's video surveillance captured the incident, showing the resident exiting past both staff members, but the video lacked a date and time stamp. Staff interviews confirmed that the required supervision and monitoring were not maintained at the time of the incident, resulting in the resident's unsupervised elopement.