Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A resident with severe cognitive impairment, including dementia and a history of alcohol dependence, was assessed as high risk for wandering and elopement. The resident had a documented history of increased wandering, previous elopement attempts, and impaired decision-making skills. The care plan included interventions such as the use of a wander guard alarm system, staff education on elopement policy, and engagement in purposeful activities. Despite these measures, the resident was able to exit the facility unsupervised and was missing for several hours. On the day of the incident, the resident exited the building, triggering the wander guard alarm. A staff member turned off the alarm without notifying other staff or verifying the resident's location. Other staff members assumed the resident was accounted for and did not physically check on him when the alarm sounded. The resident was later found outside the facility and returned by staff. Interviews revealed that staff were aware of the resident's elopement risk and the protocol for responding to wander guard alarms, which included verifying the location of all residents with wander guards and notifying staff via walkie talkies. However, these protocols were not followed during the incident. Documentation and interviews indicated that the resident had previously eloped, both before and after the implementation of the wander guard. The facility's policy stated that alarms are not a replacement for necessary supervision and that staff must respond to alarms promptly. The failure to respond appropriately to the wander guard alarm and to verify the resident's whereabouts resulted in the resident's unsupervised exit from the facility.