Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A resident with a diagnosis of toxic encephalopathy and severe memory impairment was admitted to the facility and identified as being at risk for elopement due to mental confusion and memory loss. The resident's care plan included the use of a wander management monitor, which was documented as being in place and functioning. Physician orders specified that the resident could only leave the facility with supervision. Despite these measures, the resident was able to leave the facility unaccompanied, walk several busy streets, and was eventually found by a friend who transported him to his responsible party's home. Staff interviews revealed that the resident was last seen in the facility's lobby and was discovered missing when a nurse checked on him for dinner. Neither the nurse nor the CNA assigned to the resident heard the wander management monitor alarm. The resident was still wearing the monitor when he arrived at his responsible party's home, and it was later removed with scissors. Facility policy required residents or their responsible persons to notify a licensed nurse and sign out when leaving on a pass, but this procedure was not followed. The failure to provide adequate supervision and ensure the effectiveness of the wander management system resulted in the resident's unsupervised departure from the facility.