Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of Resident R1, who was identified as having a severe cognitive impairment with a BIMS score of 5. Despite having a care plan initiated for the risk of wandering and elopement, the plan was not updated until after the incident occurred. The facility's elopement evaluations previously documented Resident R1 as not being at risk for elopement, and a significant change assessment that included an elopement risk evaluation was not completed. This lack of updated assessments and care plan adjustments contributed to the resident's ability to leave the facility unsupervised. On the day of the incident, Resident R1 was found outside the facility on a highway by a CNA, who brought the resident back. The resident was reportedly attempting to get a cigarette. The incident was confirmed by the Director of Nursing and the Regional Director of Nursing, who acknowledged the failure in supervision. The facility's policies and procedures, as well as the resident's rights, were not adhered to, resulting in the resident's unsupervised exit from the facility.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. F689 1. Resident R1 was safely returned to the facility by nurse aide. Resident R1 was assessed for injuries upon return and no injuries noted. Resident R1 was dressed appropriately for the weather. A new elopement assessment was completed 11/15/24 and wander guard placed on Resident R1. 2. The facility will provide adequate supervision to prevent elopements. Residents are evaluated for elopement risk on admission, readmission and as needed. 3. Facility staff will be re-educated on the wandering and elopement policy by the Director of Nursing/designee. 4. The Interdisciplinary Team (IDT) will meet weekly for four weeks and then monthly for three months to discuss any potential elopement risks with each department including status changes of current residents and new admissions. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.