Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A resident with severe cognitive impairment, a history of wandering, and multiple diagnoses including vascular dementia, ataxia, and a history of falls, was not adequately supervised and was able to elope from a secured memory care unit. The resident's care plan identified her as being at risk for elopement and requiring frequent checks, supervision, and staff or family escort when off the secured unit. Despite these interventions, the resident was able to leave the dining room unaccompanied after dinner, and staff did not notice her absence until later. The resident exited the secured unit by getting on the elevator with another resident's family, who had the access code. There was no alarm system in place to alert staff when a resident was attempting to exit the secured unit. The receptionist observed the resident leaving the building with what appeared to be family members but did not recognize her as a resident or consult the elopement binder, which contained photos and names of at-risk residents. Staff interviews revealed that the resident was not on the wandering list, and there was a lack of communication and supervision during the transition from the dining room to her room. The resident was found approximately 0.8 miles away from the facility, outside a local grocery store, having crossed a busy intersection without her walker. She was subsequently taken to the hospital for evaluation. Family members expressed concern that the facility did not notify law enforcement promptly and that there was no monitoring device to alert staff when a resident was leaving the building. The facility's policy required immediate notification and search procedures for missing residents, but these were not followed in a timely manner.