Failure to Prevent Elopement and Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for a resident with dementia and a high risk for wandering. The resident, who had a severely impaired cognitive status and a history of exit-seeking behaviors, was admitted with a diagnosis including dementia and was assessed as high risk for wandering. Despite the facility's policy requiring elopement risk assessments at admission and after significant changes in status, there was no evidence that an updated elopement assessment was completed after a significant change in the resident's condition. The care plan included interventions such as distraction and the use of a wander guard, with physician orders to check the device's placement and function each shift. The resident successfully eloped from the facility on two separate occasions. On both occasions, the wander guard system failed to alert staff when the resident exited through the main entrance, and there was no documentation of additional safety measures being implemented after these incidents. Staff interviews confirmed that the resident was able to leave the facility when a visitor opened the door, and surveillance footage showed no staff present at the time of elopement. The resident was found outside in the parking lot, which slopes toward a busy road and a large body of water, increasing the risk of harm. Staff also reported that the resident frequently wandered into unsecured areas, including a therapy room and storage room. Following the second elopement, the resident was found on the floor of a dark, unsecured therapy room, unresponsive and requiring transfer to the hospital for evaluation. There was no evidence that the facility implemented additional interventions or safety measures to prevent further incidents while the resident remained at the facility. The facility's failure to reassess the resident's elopement risk after significant changes in condition, lack of effective supervision, and failure to secure hazardous areas resulted in repeated elopements and an unwitnessed fall, placing the resident at risk for serious harm.