Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent accidents for one of three residents reviewed for accidents or hazards. Specifically, a resident with Alzheimer's disease and severe dementia, who was identified as being at risk for elopement and required structured activities and distractions from wandering, was able to leave the facility unsupervised. On the day of the incident, the resident was last seen at the nurses' station around 12:45 p.m. and was discovered missing shortly after lunch was delivered to his room. Staff initiated a search of the building and surrounding areas, and the police were notified when the resident could not be found. The resident remained missing for approximately 49 hours before being located within a mile of the facility. Upon being found, the resident had abrasions and required intravenous fluids at the hospital. The resident's care plan had previously identified him as being at risk for elopement and wandering, with interventions such as documenting wandering behavior, providing structured activities, and using reorientation strategies. Despite these interventions, the resident was able to exit the facility without staff knowledge or accompaniment. Interviews with facility staff revealed that the resident was not a typical dementia patient and had a history of wandering and repetitive questioning. The facility had attempted to place the resident in a secured unit prior to the incident, but this led to behavioral issues. At the time of the incident, the facility's wander guard system had not yet been updated as previously agreed upon by the former managing company, which contributed to the resident's ability to elope.