Failure to Prevent Elopement for Resident with Dementia and PTSD
Penalty
Summary
A resident with moderate dementia, PTSD, and difficulty walking was admitted to the facility and identified as being at risk for elopement, as documented in the resident's Elopement and Wandering Risk Assessment. The assessment indicated the need for a wander alarm device, and a physician's order for a wander guard was in place. However, the wander guard order was discontinued and the device was removed several months prior to the incident. The resident's care plan was also revised to indicate that the elopement risk and need for a wander guard were resolved, despite the resident's ongoing cognitive impairments and history of unsafe wandering. On the date of the incident, the resident left the facility unsupervised and was found by a family member walking down the street and standing at a traffic light intersection. Facility staff were unaware of the resident's absence until notified by the family member. Upon review, the care plan did not reflect the resident's elopement risk during the period leading up to the incident, and staff confirmed that the resident's elopement was a safety issue due to his dementia and PTSD. The facility's policy required that residents identified as at risk for wandering or elopement have care plans with appropriate interventions to maintain safety, which was not followed in this case.