Failure to Prevent Elopement of At-Risk Resident Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident identified as being at risk for elopement was able to leave the facility without staff knowledge or supervision. The resident, who had a history of confusion and was assessed as a fall and elopement risk, was admitted with a left femur fracture and had a wander guard bracelet placed on their wrist. Despite these precautions, the resident expressed a desire to leave the facility, was noted to be exit-seeking, and required standby assistance for mobility. On the day of the incident, the resident entered the facility's cafe and requested to go outside. A Dietary Aide, unaware of the resident's elopement risk and without confirming with nursing staff, assisted by opening the cafe side door, which was not equipped with a wander guard alarm system. The resident exited through this door and was later found at a gas station across a four-lane road, approximately 0.3 miles from the facility. At the time of discovery, the resident no longer had the wander guard bracelet and refused to return to the facility, requiring EMS intervention for transport. Facility documentation and staff interviews confirmed that the Dietary Aide did not check for the presence of the wander guard or consult with nursing staff before allowing the resident outside. The lack of adequate supervision and the absence of an alarm system on the cafe door directly contributed to the resident's unsupervised exit from the facility.