Failure to Prevent Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate monitoring and supervision to prevent an avoidable accident involving a resident with moderate cognitive impairment and a history of unsafe behaviors, including wandering, exit-seeking, agitation, and poor safety awareness. The resident, who was admitted with diagnoses such as Wernicke's Encephalopathy and unsteadiness on feet, was residing in a locked dementia unit. Despite the presence of door alarms and staff assigned to monitor the area, the resident was able to leave the unit undetected. Staff became aware of the resident's absence only after hearing an alarm and conducting a sweep of the unit, at which point the resident was found missing. Subsequently, the resident was located outside the facility, less than 500 feet from the driveway entrance, attempting to wheel himself away. During the attempt to evade staff, the resident tipped his wheelchair and sustained a scraped knee, necessitating hospital evaluation. Interviews with staff confirmed that the doors were equipped with alarms and that staff were expected to be present in the hallways and dining areas. However, the monitoring in place was insufficient to prevent the resident's elopement and subsequent injury. Facility policy required identification and prevention of unsafe wandering, but the measures in place did not prevent this incident.