Failure to Prevent Elopement Due to Inadequate Supervision and Security System Lapse
Penalty
Summary
A resident with diagnoses of Alzheimer's disease, dementia, and traumatic brain injury, who was assessed as severely cognitively impaired and at risk for elopement, was admitted to the facility. The resident's care plan included interventions such as one-on-one supervision and the use of a wander guard device. On the day of the incident, the resident was left unsupervised when the assigned CNA left to answer another resident's call light. During this time, the resident exited the facility through the front door while emergency medical services were present for another resident, and the wander guard system did not alarm. The resident was discovered missing after a headcount and was later found outside on the facility grounds by an independent living resident. The facility's investigation revealed that the wander guard system could be temporarily disabled when the exit door code was entered or the unlock button at the receptionist desk was pressed, allowing the resident to leave undetected. Staff interviews and policy review confirmed that the resident did not receive the required supervision as outlined in the care plan, and the security system in place at the time allowed for this lapse in monitoring.