Failure to Prevent Elopement Due to Inadequate Supervision During High Visitor Volume
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, and a known history of wandering was not adequately supervised during a period of increased visitor activity. The resident was independent with ambulation and transfers, and care plans identified wandering behaviors with interventions to redirect and provide structured routines. Despite these interventions, the resident was able to leave the secured memory care unit unsupervised while visitors were entering and exiting the unit in large groups. On the day of the incident, there were several out-of-state visitors unfamiliar with the facility, as well as ongoing construction and a social worker present, contributing to a busier environment than usual. Staff interviews revealed that the resident likely exited the secured unit alongside visitors when the door was opened for them. The staff member responsible for entering the secure door code did not remain at the door to ensure no residents exited, as required by facility policy. The resident then proceeded through two hallways and exited the main facility entrance without being noticed by the receptionist or other staff. The facility was unaware that the resident had left until notified by the police, who found the resident 0.4 miles away from the facility. Documentation and interviews confirmed that staff did not provide the necessary supervision or monitoring at exit points during peak visitor times, as outlined in the facility's elopement prevention policy. This lapse in supervision allowed the resident to leave the secured area and the facility without detection.