Failure to Prevent Elopement of Resident with Cognitive Impairment
Penalty
Summary
A resident with Alzheimer's disease and severe cognitive impairment, who had a history of exit-seeking behaviors, was able to elope from the facility. The resident had previously demonstrated elopement behaviors, including attempting to follow a hospice volunteer out the door, which resulted in the implementation of every 15-minute checks. However, these checks were discontinued after the resident reportedly showed no exit-seeking behaviors for two days. Subsequently, the resident left the facility unassisted and was found by local police in a nearby residential neighborhood. The facility had identified multiple residents at risk for elopement and had policies in place to assess and monitor these individuals. Despite these measures, the resident was able to exit the building by following someone out the door, indicating a lapse in supervision and monitoring. Documentation showed that the resident was last seen in a common area by a certified nurse aide, but was later discovered missing, prompting a search and eventual recovery by law enforcement.