Failure to Prevent Elopement of Resident with Dementia from Secured Unit
Penalty
Summary
A resident with a diagnosis of dementia, agitation, and a history of exit-seeking behaviors was admitted to the facility and initially placed on one-to-one supervision with a wander guard device applied to his ankle. The resident was assessed as an elopement risk, and his care plan included monitoring for wandering triggers and the use of a secured unit if needed. After several days of one-to-one supervision, the resident was transferred to a secured dementia unit, at which point the wander guard and one-to-one supervision were discontinued due to the unit's locked status. Despite residing on the secured unit, the resident was able to exit the facility when a visitor entered the code to the egress door and held it open, allowing the resident to leave unsupervised. Staff interviews and video footage confirmed that the resident exited the building with the assistance of the visitor and was not immediately noticed as missing by facility staff. The resident was unaccounted for outside the facility for approximately 50 minutes, during which time he walked across a four-lane highway and traveled nearly 0.7 miles away from the facility. The resident was eventually located by a staff member who was arriving for work and observed him walking near a park. The staff member returned the resident to the facility by car. At the time of the incident, the facility's policy required staff to attempt to prevent disoriented residents from exiting, but the policy was not effectively implemented in this case, resulting in the resident's unsupervised elopement.