Failure to Supervise High-Risk Wanderer Resulting in Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent elopement for a resident with Alzheimer's disease and dementia who had documented daily wandering and rejection of care, severe cognitive impairment (BIMS score of 6), and a history of a fall prior to admission. The facility’s elopement and wandering policies required proactive assessment of elopement risk, identification of risk factors, and implementation of appropriate interventions in the care plan. The resident’s MDS documented daily wandering, and the care plan identified elopement risk and exit-seeking behavior, with interventions including 1:1 supervision while outside, close observation of the resident’s location, and frequent observation and redirection when exit-seeking behaviors were noted. Despite these identified risks and care plan interventions, the resident exited the building unsupervised. The facility’s own incident report concluded that the resident left the building when an exit door was remotely opened for another resident and that this door was not within staff’s line of sight. The assigned LPN reported that the resident had exhibited exit-seeking behaviors since admission, such as going to the door with personal belongings, and that staff were monitoring the resident every 15 to 30 minutes to ensure she remained in the building. On the day of the incident, the LPN stated the resident likely exited when doors were unlocked due to a generator outage and followed another resident, after which she was found across the street near a nearby college.
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