Resident Elopement Due to Inadequate Supervision and Exit Security
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dementia and falls was able to elope from the facility. The resident, an elderly female with a BIMS score indicating severe cognitive impairment, was not identified as an elopement risk on her initial assessment, but her care plan did indicate a need for routine monitoring due to her cognitive status and risk for falls. On the day of the incident, the resident exited the facility when a visitor held the door open for a CNA entering the building. The CNA, who worked on the secured unit and was unfamiliar with the resident, did not recognize her as a resident because she was dressed in a way that resembled a visitor and was carrying a purse. The resident was found outside the facility by a passerby and was returned by a member of the public. Staff interviews revealed that the resident was not outside for more than five minutes and did not sustain any injuries. The incident was not immediately recognized by staff, and the CNA involved later acknowledged not recognizing the resident as someone who should not be leaving the building. The facility's security measures, including non-functioning cameras and lack of staff presence at the front door, contributed to the resident's ability to leave unnoticed. The facility's policies required the environment to be as free from accident hazards as possible and for residents to receive adequate supervision to prevent accidents, including unsafe wandering. However, the failure to recognize the resident as a resident, combined with the lack of effective monitoring and security at the exit, resulted in the resident's elopement. The incident was identified as Immediate Jeopardy, as it placed the resident at risk for harm.