Elopement Through Bedroom Window From Secured Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to prevent a cognitively impaired resident from leaving the building without staff knowledge. The resident had been admitted with diagnoses including dementia, hypertension, anxiety, and skin cancer, and an elopement risk evaluation completed on admission indicated the resident was not at risk for elopement. A subsequent comprehensive MDS assessment documented that the resident was severely cognitively impaired, required assistance or supervision with multiple ADLs, and was independently mobile. Despite this, the resident resided on a secured memory care unit and had a Wanderguard in place per physician orders. On the day of the incident, the resident was last observed by staff at approximately 8:40 a.m., walking to his room, lying on his bed, and shutting his door, which staff described as his normal routine. Staff reported that the resident was calm, pleasant, cooperative, and commonly stayed in his room with the door closed, and he had not expressed agitation or a desire to leave that day. At some point after being last seen, the resident broke the safety screw securing his bedroom window, removed the window screen, placed the screen under his bed, and exited the building through the window without staff awareness. The facility became aware of the elopement when an individual in the community called to report seeing the resident walking in the area, and emergency services and police were notified. The resident was located by police and EMS approximately 2.5 miles from the facility and returned. Upon return, vital signs were taken and a head-to-toe assessment was completed, with no injuries noted. The incident met the facility’s definition of elopement as the resident left a safe area without the facility’s knowledge or supervision, demonstrating a failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents.
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