Failure to Prevent Elopement from Secured Unit
Penalty
Summary
A deficiency occurred when a resident with a history of elopement and cognitive impairment was able to leave the secured unit of the facility through a window. The resident had previously attempted to escape through a window at another facility and was admitted to the secured unit based on family input and prior history. Despite being identified as a high-risk wanderer and having a care plan that included interventions such as monitoring during rounds and diversional activities, the resident was able to open a window and exit the facility undetected by staff. On the day of the incident, staff discovered the resident missing during meal tray distribution and found the window in the resident's room open. There were no alarms on the windows in the secured unit, and the window screen had been pushed out. Staff initiated the elopement protocol and notified law enforcement, but there were no witnesses to the resident leaving. The resident was later located at a previous residence by a neighbor, but staff were unable to assess the resident for possible injury after the elopement. Interviews with facility staff revealed that the resident did not display exit-seeking behaviors prior to the incident and was considered quiet and pleasant. The decision to place the resident in the secured unit was based on prior elopement attempts and family recommendations, rather than solely on cognitive assessment scores. The facility's elopement prevention policies required monitoring and specific interventions for high-risk residents, but the lack of window alarms and the ability for windows to be opened wide enough for egress contributed to the resident's ability to elope.