Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision to prevent a resident with severely impaired cognition and a known risk for elopement from leaving the facility unsupervised. The resident had diagnoses including emphysema, malignant neoplasms, a history of TIA, and cerebral infarction without residual deficits. The care plan identified the resident as an elopement risk due to exit-seeking behaviors and lack of awareness of safety needs, with interventions including a Wanderguard device and regular safety checks. Despite these measures, the resident was able to exit the facility undetected. On the day of the incident, multiple staff members observed the resident in various locations throughout the morning and at lunchtime. The resident was last seen in the dining room and later in her room, but was not directly supervised at all times. Staff became aware of the resident's absence when a CNA attempted to bring her to an activity and found her missing. A search was initiated, and it was discovered that the resident had left the facility by following a visiting family member onto the elevator and out the front door. Video surveillance confirmed that the resident exited the building behind the visitor, who was unaware of the resident's risk and did not notice her leaving. The facility's elopement policy was reportedly followed after the resident was found missing, but the event was not reported to the State Agency. The incident highlighted a lapse in supervision and monitoring, as the resident was able to leave the premises without staff detection, despite being identified as an elopement risk and having interventions in place. The resident was later found safe at a nearby hospital emergency department, having checked herself in without injury.