An assisted-living facility (ALF) in Arizona was fined $500 and, under a settlement, agreed to implement stricter safety measures following an incident in which an 85-year-old man with Alzheimer’s disease wandered from the facility and died.
The resident, a retired teacher, had been living at the facility for less than a month when he left unsupervised on a June afternoon. Staff did not notice him leaving, according to a police report. When he wasn’t found, the Arizona Department of Public Safety issued a Silver Alert—a public notification system aimed at finding missing vulnerable adults, particularly those with cognitive impairments like Alzheimer’s disease.
Two days later, a neighbor discovered the resident behind her home, unresponsive, and contacted 911. She told the 911 operator that she thought he was the missing man.
The Arizona Department of Health Services (ADHS) investigated and cited the facility for failing to implement strategies to ensure the resident’s safety. A state inspector found that the facility’s front door alarm was not functioning at the time of the inspection.
The facility was fined $500, according to state records. Under a settlement with ADHS, the facility denied any liability or wrongdoing but agreed to implement safety measures, including:
- Unannounced state inspections.
- A manager on-site at least 15 hours a week.
- Training for all staff on managing residents with dementia.
- Policies for monitoring residents who are at risk of leaving the facility.
Compliance Perspective
Issue
Facilities must identify and assess residents’ risk of leaving without staff notification and develop interventions to mitigate this risk. This includes implementing clear policies and procedures for assessing, monitoring, and managing residents at risk of elopement. Such measures help minimize the risk of a resident leaving a secure area without the facility’s awareness or appropriate supervision. Early assessment is key. Residents should be assessed upon admission and at least quarterly thereafter. Additional risk assessments should be conducted following any change in a resident’s condition. At-risk residents should have specific interventions included in their comprehensive care plans to address elopement risks. Staff must document the implementation of these policies. Additionally, the facility’s disaster and emergency preparedness plan should include protocols for locating a missing resident. A critical component of elopement prevention is ensuring that all safety alarms, including door alarms, are functioning properly. Regular inspections and maintenance of these systems should be part of the facility’s ongoing safety protocol.
Discussion Points
- Review policies and procedures related to preventing resident elopement. They should include protocols for identifying residents at risk, ensuring adequate monitoring, staffing levels, and security measures to prevent wandering. Consider adding or updating policies for surveillance systems if necessary, and ensure door alarms are regularly tested and maintained.
- Train staff on the importance of monitoring residents, particularly those with cognitive or physical impairments. Conduct regular elopement drills to ensure that all staff, across shifts, know how to respond if a resident is missing.
- Periodically audit to confirm that residents’ elopement risk assessments are conducted upon admission and updated quarterly or as needed. Ensure staff are following through on assigned checks and documenting their observations. Use audits to monitor compliance with care plans and identify areas for improvement in resident monitoring, including checking the functionality of security systems like door alarms.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*
