Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident with severe dementia and multiple comorbidities, including Alzheimer's disease, psychotic disorder, and unsteadiness on his feet. The resident was assessed as high risk for elopement, with a documented history of wandering and a care plan that included specific interventions such as distraction, structured activities, and staff notification if exit-seeking behavior was observed. Despite these interventions, the resident was able to leave the facility unsupervised. On the day of the incident, the resident was last seen in the TV area after returning from a smoke break with other residents and staff. The facility's front door was secured with a keypad and posted with signs instructing visitors not to allow residents to exit. However, there was no staff stationed at the door, and a visitor later reported that he had allowed the resident to exit with him, mistakenly believing the resident was another visitor. Staff did not hear any door alarms, and the resident was not immediately noticed missing. The resident was found by community members sitting outside less than 0.2 miles from the facility, confused and with a bandage on his eyebrow, and was subsequently transported to the hospital for evaluation. Interviews with staff and the resident's power of attorney revealed that the resident was generally considered redirectable and not expected to elope, despite his high-risk assessment. Staff described routine in-services on elopement prevention and response, but acknowledged that the resident was able to leave the facility undetected during a period of increased visitor traffic. The facility's elopement risk assessments and care plan interventions were not sufficient to prevent the resident's unsupervised exit.