Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent a resident from eloping. The resident involved had significant cognitive impairment, as indicated by a BIMS score of six out of fifteen, and diagnoses including Parkinson's Disease with dyskinesia, dementia with agitation, and a traumatic brain injury. The care plan identified the resident as an elopement risk, with interventions such as a wander guard and monitoring per shift, but these were not effectively implemented at the time of the incident. On the day of the incident, the resident was observed in the lobby, pacing, and later left the facility at an unknown time. Multiple staff interviews revealed that the resident exited the building without a wander guard in place and was not identified by staff as leaving. The resident was later found outside the facility by a staff member and a police officer, having crossed a street and nearly reached a freeway. Staff were unable to determine which door the resident used to exit, and it was noted that someone would have had to unlock the door for the resident to leave, but no staff could confirm who did so or how the resident was able to exit undetected. Facility policy required the use of door alarms, monitoring devices, and regular checks of wander guard devices, but these measures were not followed or were ineffective in this case. Staff interviews confirmed that the resident did not have a wander guard on at the time of elopement, and the required monitoring and documentation were not completed. The failure to supervise and monitor the resident according to the care plan and facility policy resulted in the resident's unsupervised exit from the facility.