Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, non-Alzheimer's dementia, non-traumatic brain dysfunction, and Parkinson's disease was not provided with adequate supervision to prevent elopement. The resident had a history of wandering and exit-seeking behaviors, as evidenced by high scores on multiple Wander Data Collection assessments. On the day of the incident, the resident was observed repeatedly attempting to exit through the front door, triggering the wander guard alarm twice. Staff redirected him both times, but did not implement increased supervision or notify facility administration as required by policy. Despite the resident's ongoing agitation and repeated exit-seeking behavior, the charge nurse failed to place the resident on one-to-one supervision or escalate the situation to administration. The resident ultimately left the facility by following others out the front door, with the wander guard system functioning properly. He was found by police down the street and returned to the facility without injury. Staff interviews confirmed that the resident was visibly upset and determined to leave to find his wife, and that staff were aware of his behaviors but did not take additional steps to ensure his safety. The facility's policy required immediate response to door alarms, investigation of the cause, and accounting for residents at risk for elopement. However, these procedures were not fully followed, as the charge nurse did not notify administration or implement one-to-one supervision after multiple exit attempts. The lack of timely intervention and supervision directly led to the resident's elopement from the facility.