Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent a cognitively impaired resident from leaving the building unsupervised despite known elopement risk and wandering behaviors. The resident had vascular dementia with behavioral disturbance, severe cognitive impairment, and a documented history of restlessness, pacing, intrusive behavior in peers’ rooms, calling out for parents, and repeated attempts to exit the facility. An elopement/wandering assessment identified behaviors such as attempting to leave without a responsible escort, pacing and roaming, and becoming agitated while looking for family, with a plan to use a wanderguard device. Nursing notes prior to the incident documented that the resident had been combative, agitated, exit seeking, going into other rooms, and difficult to redirect, with frequent checks maintained. On the day of the elopement, the resident, who was identified as an elopement risk, exited the facility through door #4 without staff knowledge. The door alarm did activate, but staff did not hear it due to environmental noise at the nurses’ station. The resident was later found outside by the door, tapping on the window to be let back in, and was brought back into the building by an activity aide who arrived early for her shift and heard the tapping. Staff interviews indicated that the resident frequently wandered, persistently went to multiple doors, twisted knobs, pushed on doors, and tried to get out, and that she did not take redirection well. Following the incident, staff interviews revealed that door #4 on the memory care unit was found disengaged and unlocked, and no one reported hearing an alarm at the time the resident exited. A CNA reported that when she checked the doors after the resident was returned, door #4 was disengaged and could be opened without the alarm sounding. Housekeepers working in nearby hallways also stated they did not hear any alarm, even though they described the alarms as typically very loud and easily heard from their work areas. Maintenance staff explained that the door system required the alarm to be engaged for it to sound when pushed, and that if it was disengaged, the door could be opened without triggering an alarm. The facility’s elopement and wandering policy stated that the facility is equipped with door locks/alarms to help avoid elopements, that alarms are not a replacement for necessary supervision, that staff must be vigilant in responding to alarms, and that adequate supervision will be provided to help prevent accidents or elopements, which did not occur in this case.
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