Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including anxiety, depression, vascular dementia with behaviors, and stage 3 chronic kidney disease was identified as being at risk for elopement, as documented in their care plan and elopement risk assessment. The resident resided on a secured unit and had a history of exit-seeking behaviors, such as shaking and pushing at doors. Despite interventions in place, the resident was able to leave the secured unit unsupervised on two occasions. On one occasion, the resident was found wandering outside the secured courtyard fence, near the parking lot, without staff supervision. It was not clear how long the resident had been outside before being found by a CNA who was on break. Interviews with facility staff revealed that the doors on the unit were supposed to be secure, and staff and visitors were reminded to ensure doors were closed tightly and to prevent residents from following them off the unit. However, during an activity in the courtyard, the resident was able to exit the secured area and was later found outside the building. Security video confirmed the resident exited the building and was outside for less than three minutes before being brought back inside by a CNA. The incident demonstrated a failure to provide adequate supervision and to ensure the area was free from accident hazards for a resident at risk for elopement.