Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A resident with moderate cognitive impairment, a legal guardianship in place, and a history of leaving the facility without notifying staff was not provided with adequate supervision to prevent elopement. The resident was assessed as being at risk for elopement and required supervision for ambulation. Despite this, multiple nurse's notes documented several occasions where the resident left the facility without signing out, was seen in the community or along the roadway, and staff were unaware of the resident's whereabouts for extended periods. Staff interviews confirmed that the resident was frequently noncompliant with supervision, ambulated outside alone, and was not fully understanding the risks involved. Concerns about the resident's safety and cognitive status were noted by both nursing and medical staff, with cognitive testing ordered to further assess the situation. The facility's elopement policy required staff to determine if a resident was out on authorized leave and to notify administration if not. However, documentation and interviews revealed that staff were often unaware when the resident left, and the required notifications and interventions were not consistently implemented. The Director of Nursing and Administrator acknowledged the resident's inability to safely leave the facility alone and that the guardianship arrangements were not sufficient to ensure safety. Despite repeated incidents and staff concerns, the resident continued to elope without adequate supervision or effective preventive measures in place.