Failure to Supervise Resident with Dementia Resulting in Elopement and Exposure
Penalty
Summary
A resident with dementia, moderate cognitive impairment (BIMS score of 10), and a court-appointed conservator was admitted with multiple diagnoses including cardiomyopathy, nicotine dependence, and chronic kidney disease. The resident was care planned for dementia, poor judgment, and required assistance with activities of daily living (ADLs), but was noted to ambulate independently. There were no physician orders for a leave of absence, and the resident was not identified as an elopement risk by staff. On the day of the incident, the resident was last seen by staff in the dining room and lobby around 5:40 PM, wearing two coats and shoes, but left the facility at 5:36 PM as confirmed by video footage. Staff did not notice the resident's absence until notified by local police at 8:15 PM, over two hours later. The resident was found by police approximately half a mile from the facility, lying face down in a snowbank, confused, wet, and missing a shoe. Emergency services responded, removed wet clothing, and transported the resident to the hospital, where the resident was diagnosed with a fall and frostnip. The resident reported leaving the facility to buy cigarettes but could not recall the timing or duration of the absence. The outside temperature at the time was 13°F with light snow, and the resident was found in a residential area along a main road with a 45 mph speed limit. Documentation and interviews revealed that staff did not monitor the resident's whereabouts or meal consumption after the resident left the facility. Nursing assistants and nurses assumed the resident was either in their room or visiting another unit, as the resident often ate meals later and ambulated independently. There was a lack of communication between dining room and unit staff regarding the resident's location and meal intake. The facility was unable to provide a policy regarding routine monitoring of residents for safety, and there was no documentation of ADL tasks for the resident during the relevant shift. Staff were unaware of the resident's absence for 2 hours and 39 minutes until police notification.