Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident with severe cognitive impairment and a very high elopement risk score of 14. The resident had diagnoses including unspecified dementia with anxiety and mood disturbance and was care planned with a goal that the resident would not leave the facility without a responsible party, with an intervention to assure an identification band or other form of identification was in place. Physician orders directed staff to check the placement of a wander guard on the resident’s left ankle every shift, monitor skin, and notify the physician as needed. Staff interviews revealed that the resident frequently attempted to elope and would remove or cut off the wander guard. According to the Director of Staff Development, the resident left the facility through a door near the smoking area, unlatched a gate, and walked to a road behind the facility, where a truck picked the resident up and transported the resident to a nearby apartment complex, and a person there called 911. A nurse who was present on the day of elopement stated she did not hear an alarm and confirmed the resident had a history of trying to elope and manipulating or removing the wander guard. During an observation in the resident’s room, the resident was not wearing an identification band, and the nurse confirmed this finding. The DON acknowledged that a wander guard is only effective when worn and that residents have the right to be safe in the facility. The facility’s wandering and elopement policy stated that the facility will identify residents at risk of unsafe wandering and strive to prevent harm.
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