Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Alzheimer's disease, and a high risk for elopement exited the facility unsupervised. The resident was equipped with a WanderGuard device and had a care plan identifying elopement risk, including interventions such as monitoring the WanderGuard device and documenting wandering behavior. On the evening of the incident, the resident was last seen following a nurse during medication pass and was later observed on camera following a visitor out the front door. Despite the WanderGuard alarm sounding at the main entrance, the registered nurse on duty turned off the alarm without immediately investigating outside to determine if a resident had exited. The nurse and a CNA began searching for the resident only after noticing his absence from the hallway and rooms. The facility initiated a code white and staff searched both inside and outside the building, but the resident was not located until approximately nine hours later by local police, two miles away from the facility. Interviews and record reviews confirmed that the resident was known to pace the hallways and follow people, and had a history of elopement risk. The nurse on duty did not respond to the WanderGuard alarm as required, and the resident was able to leave the facility by following a visitor, which was not immediately detected by staff. The failure to provide adequate supervision and to respond appropriately to the WanderGuard alarm resulted in the resident's prolonged absence from the facility.