Failure to Prevent Elopement of Resident with Dementia and Wandering Behaviors
Penalty
Summary
A resident with dementia, severe cognitive impairment, and a known history of wandering and exit-seeking behaviors exited the facility unsupervised despite being on a secured locked unit and wearing a wanderguard device. The resident was able to leave the secured unit through an unlocked stairway door, descend to the first floor, and exit the building through an unlocked but alarmed door. The stairway door was supposed to be locked and checked daily by the Maintenance Director, but it was not checked on the day of the incident. The exit door alarm sounded, but staff reset the alarm without investigating the cause or checking outside, and the resident was not immediately located. The resident wandered approximately 0.4 miles away from the facility, crossing a two-lane road before being found by a CNA walking in the grass along the road. The resident's care plan and assessments documented her high risk for elopement, use of a wanderguard, and previous incidents of exit-seeking, including a prior event where she left the building and required intervention. Despite these documented risks and behaviors, there were no updated interventions in the care plan after the previous elopement incident, and the facility's elopement policy did not specify staff response to door alarms. Interviews and record reviews revealed that staff were not aware of the resident's exit until a code for a missing resident was called, and the alarmed door had been tampered with, preventing it from locking properly. Staff responding to the alarm did not open the door or check the area outside, and only later realized the resident was missing. The resident was eventually found without injury, but the incident demonstrated a failure to ensure the environment was free from accident hazards and that adequate supervision and monitoring were provided to prevent accidents for residents at risk of elopement.