Failure to Prevent Elopement of Resident Identified as Wandering Risk
Penalty
Summary
A deficiency occurred when a resident, identified as an elopement risk with a history of major depression and epilepsy, was able to leave the facility without staff knowledge or intervention. The resident was assessed as alert and oriented, with a BIMS score of 14, and was independent in ambulation using a walker. Despite being under a voluntary court-appointed conservatorship and having interventions in place such as a wander guard and an elopement care plan, the resident was able to exit the facility and cross a street to access a library on another part of the campus. On the day of the incident, the resident exited through the front doors, triggering the wander guard alarm. The security guard at the front desk deactivated the alarm without interacting with the resident or notifying nursing staff, allowing the resident to leave the building. The security guard later stated he did not realize the alarm was triggered by this resident, as he was unaware of the resident's current status as a nursing home resident with a wander guard. The resident was later observed by an LPN returning from the assisted living facility across the street and was escorted back to the building by staff, with no injuries reported. Further review revealed that the facility did not have a specific wander guard policy, although their general policy on elopements and wandering residents directed that adequate supervision should be provided to prevent such incidents. The lack of staff awareness regarding the resident's elopement risk status and the improper response to the wander guard alarm directly contributed to the resident's unsupervised exit from the facility.