Failure to Supervise Resident at Risk for Elopement During Outing
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with a history of wandering and severe cognitive impairment. The resident, who had diagnoses including Alzheimer's disease, dementia, and PTSD, was assessed as having severely impaired cognition and was known to be at risk for elopement. The resident's care plan specified that they should be kept in line of sight when outside the memory care unit. During an off-campus outing to a city parade, the resident was left unsupervised on a bench while staff assisted other residents onto a bus. Staff did not maintain line-of-sight supervision, and the resident wandered away from the group undetected. Interviews with facility staff revealed that only one nursing assistant accompanied the group, and the process for supervising residents at risk for wandering was not adequately followed. The recreation specialist and the director of nursing both acknowledged that residents from the memory care unit, especially those with wandering behaviors, should have one-on-one supervision during outings. The lack of appropriate supervision and failure to adhere to the resident's care plan resulted in the resident's elopement, as staff did not realize the resident was missing until minutes later.