Elopement of Cognitively Impaired Resident From Locked Memory Unit
Penalty
Summary
The facility failed to ensure adequate supervision to prevent an elopement for a resident identified as an elopement risk and wanderer. Facility policy on Elopement Prevention required that residents be properly assessed and care planned to prevent accidents related to wandering or elopement, including completion of a Wandering Risk Assessment upon admission, readmission, quarterly, and as needed, and development of a comprehensive elopement prevention care plan when warranted. The resident’s MDS showed diagnoses of depression, dementia, and anxiety, and Section C0100 indicated the resident was rarely/never understood, with the BIMS not completed. The resident’s care plan, dated 5/22/24, identified the resident as an elopement risk/wanderer based on a history of attempts to leave home unattended prior to admission and included interventions such as identifying patterns of wandering and monitoring the resident’s frequent location. On the date of the incident, documentation showed the resident was observed ambulating outside the locked memory unit on another resident hallway, approximately 36 feet from the memory unit. An interview revealed that the resident’s husband had visited and exited the locked unit, believing the resident was far enough from the door when he left and stating he was in a hurry and did not look behind him. A witness statement from an LPN indicated the resident followed the husband out of the unit and staff later noticed the resident in the hallway and returned the resident to the locked memory unit. Review of progress notes from 6/1/25 through 1/28/26 showed documented behaviors for the resident but none were exit-seeking. The DON stated that when she worked in the locked memory unit, the resident’s husband would come and go because he knew the door code. The NHA and DON confirmed that the facility failed to ensure each resident received adequate supervision, resulting in this elopement event.
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