Elopement of Cognitively Impaired Resident Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a cognitively impaired resident with a history of wandering from exiting the building unattended. The resident had diagnoses including dementia with agitation and a BIMS score of three, indicating severe cognitive impairment. The resident had been readmitted from a geriatric psychiatric hospitalization and was known by the DON to have a history of wandering. Despite this, the interdisciplinary team had previously determined that the resident was not at risk for elopement, and no elopement interventions such as a wander guard were in place at the time of the incident. On the day of the event, a visitor observed the resident standing near the front door and exited the facility without realizing the resident followed him outside. Staff later became aware that the resident was missing, and an LPN assisted in locating the resident. A CNA ultimately found the resident outside on the front porch and returned the resident to the facility, with the investigation determining the resident had been outside unattended for approximately five minutes. Staff interviews confirmed that the resident ambulated in the halls and had not previously attempted to exit the building, and that the resident was only reassessed and provided with a wander guard after the incident.
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