Failure to Prevent Elopement of At-Risk Resident Due to Inadequate Supervision and Staff Training
Penalty
Summary
A resident assessed as cognitively impaired and at risk for elopement, with a history of previous elopement attempts, exited the facility undetected. The resident was admitted from the hospital with diagnoses including deafness, dementia related to a communicable disease, and altered mental status. Hospital records indicated the resident lacked capacity and had a history of attempting to leave care settings. Upon admission, the resident was identified as an elopement risk, and a wander alert device was placed on their ankle. The care plan included interventions such as ensuring proper placement and function of the wander alert device, informing staff of the elopement risk, and providing the resident's picture to security. Despite these measures, the resident was able to leave the facility without detection. On the day of the incident, the resident was last seen at 10:00 AM during hourly monitoring. Surveillance footage showed the resident leaving their room, entering the elevator, and exiting through the main lobby. The security guard at the front desk released the door for the resident, mistaking them for an employee, and did not recognize the activation of the wander alert alarm. The security guard heard a beeping sound after the resident exited but did not investigate, search the lobby, or notify other staff. The security guard later stated they had not been educated on the wander alert system or the appropriate response to an alarm. The resident's absence was not discovered until a visual check at 11:00 AM, at which point a search and Code Yellow were initiated. Interviews with staff revealed gaps in monitoring and communication. The certified nursing assistant assigned to the resident did not observe the wander alert device during vital sign checks and was unaware of the resident's whereabouts until after the elopement. The security guard was new and had not received training on elopement prevention or the wander alert system. The resident's picture had not been obtained for security purposes, and there was no documented evidence of staff education on the wander alert system. The facility's policies required the use of wander management systems and staff accountability for resident safety, but these were not effectively implemented, resulting in the resident's undetected elopement.