Failure to Prevent Elopement and Injury in Cognitively Impaired Resident
Penalty
Summary
A resident with a history of traumatic brain injury, subdural hemorrhage, dementia with behavioral disturbances, and other significant medical conditions eloped from the facility's secure memory care unit. The resident was known to have severely impaired cognition, required substantial assistance with activities of daily living, and had a documented risk for elopement and wandering. On the day of the incident, the resident was observed to be agitated, demanding to go home, and was last seen at the nurse's station before propelling a wheelchair down the hallway, transferring out of the wheelchair, and exiting through a door that sounded an alarm. Shortly after, the resident was found in the facility parking lot by visitors, sitting on the ground with a laceration to the forehead. Staff responded, brought the resident back inside, and the resident was subsequently sent to the emergency room for evaluation due to the head injury and history of anticoagulant use. The resident returned later with sutures to the forehead and additional bruising, but imaging was negative for further injury. Interviews with staff and practitioners confirmed that the resident was known for frequent wandering and exit-seeking behaviors, and staff were expected to monitor the resident and respond to door alarms. The deficiency occurred due to the facility's failure to provide adequate supervision and prevent the resident from eloping, despite the resident's known risks and behaviors. The resident was able to leave the secure unit, exit the building, and sustain an injury before being found and assisted by staff.