Failure to Supervise and Prevent Elopement for Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent elopement for a resident with severe cognitive impairment and a known risk for wandering. The resident, who had diagnoses including Alzheimer's disease, dementia, PTSD, delirium, and anxiety, was care planned for elopement risk and had a WanderGuard device in place. On the day of the incident, the resident made multiple attempts to exit the unit and was redirected by staff, but no increased supervision was implemented despite the resident's persistent exit-seeking behavior. During a period of high activity with many visitors present, the resident was able to exit the facility through a second-floor stairwell door that was equipped with a functioning alarm. A family member of another resident silenced the alarm and informed staff, who were occupied with other residents and did not follow the facility's elopement procedures. Specifically, staff did not conduct a head count or check the perimeter after being notified of the alarm. As a result, staff were unaware that the resident had left the facility until the police notified them after finding the resident 0.6 miles away in a hospital parking lot, inadequately dressed for the cold weather. Interviews and record reviews revealed that agency staff working that shift had not received orientation or training on the WanderGuard system, and family members had access to alarm codes, allowing them to silence alarms. The facility's investigation was unable to determine exactly how the resident eloped without staff knowledge, but it was clear that staff failed to follow established elopement procedures, including immediate response to alarms, perimeter checks, and head counts. This failure resulted in a finding of immediate jeopardy due to the reasonable likelihood for serious harm.
Removal Plan
- Initiated checks for R1 and updated R1's care plan.
- Changed alarm keypad codes to ensure family members/visitors do not have access to codes or a means to clear alarms.
- Instructed maintenance staff to change the codes at intervals.
- Educated staff on the facility's elopement policy, door alarm system, and new procedure for elevator/door codes.
- Completed elopement drills and tested both systems.