Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with Alzheimer's Disease and moderate cognitive impairment. Upon admission, the resident was assessed for elopement risk and scored as low risk, but the care plan identified the resident as being at risk for elopement due to dementia and included a wander prevention band. Despite these measures, the resident was able to exit the building when the receptionist released the front door lock, allowing multiple visitors and the resident to leave the premises. The incident report and staff witness statements confirm that the resident left the building and was later found in the parking lot near the road by a nurse aide. The wander guard alarmed only when the resident re-entered the building. The event was confirmed by the DON, who provided the timeline of the resident's exit and subsequent recovery. The deficiency was cited under regulations related to the responsibility of the licensee, resident care policies, and nursing services.