Failure to Supervise Elopement-Risk Resident with Dementia
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident with dementia and known exit-seeking behaviors, resulting in an elopement event. The resident, who had diagnoses including dementia with mood disturbances, severe depression with psychotic symptoms, and anxiety, had a documented history of wandering, exit seeking, and threatening self-harm. A recent MDS assessment showed wandering behaviors and care plans identified the resident as an elopement risk with exit-seeking behaviors, with a goal that the resident would not elope and would be redirected away from doors and exits as needed. An observation report documented that the resident was oriented only to person and had a history of exit seeking, and a physician note described recent exit-seeking behaviors and refusal of sleep and medications. On the day of the incident, after finishing supper, the resident returned to his room, put on a winter coat, and then exited the building through the main front door. Photographs provided by the Administrator showed the resident leaving through the main entry, walking along the asphalt drive around the side of the building, and later being outside near the courtyard before staff escorted him back inside through doors near the courtyard. During this time, there was an approximate two-minute period when the resident was not visualized and was unsupervised. The incident report and nursing progress note indicated that another resident and family in the foyer observed the resident leaving, and memory care staff noticed the resident outside and brought him back in. The Administrator stated that although the resident was wearing a magnetic alarm mechanism, it failed to alarm when the resident opened the front door and exited. The facility’s elopement risk assessment and prevention policy required implementation of prevention strategies and a plan of care for residents identified as having the potential to leave the facility unauthorized and requiring supervision for wandering to unsafe areas.
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