Failure to Reassess Elopement Risk for Resident with Cognitive Decline
Penalty
Summary
The facility failed to reassess a resident with cognitive decline for elopement risk, leading to a deficiency. Resident R1, who was diagnosed with dementia and mood disturbance, exhibited a significant decline in cognitive function over several months, as evidenced by a decrease in BIMS scores from 14 and 15 to 5. Despite this decline, the resident's care plan did not include goals or interventions for dementia or cognitive decline, and the facility did not complete a new elopement risk assessment after the resident's cognitive status changed. The resident's clinical records and staff notes indicated ongoing memory problems, confusion, and episodes of anxiety, such as worrying about his truck and attempting to leave the facility to check on it. On one occasion, the resident was found outside the facility on the highway, indicating a clear risk of elopement. Despite these incidents, the facility's elopement evaluations had previously documented the resident as not being at risk for elopement, and a significant change assessment initiated in September was not completed. Interviews with the Director of Nursing and the Regional Director of Nursing confirmed that the facility did not reassess residents with cognitive decline for elopement risk as required. The facility's failure to complete the necessary assessments and update the resident's care plan contributed to the resident's ability to leave the facility unsupervised, posing a potential risk to the resident's safety.
Plan Of Correction
F744 1. The facility cannot correct that Resident R1 was not reassessed for elopement with a cognitive decline until 11/15/24. 2. The Social Service Director/designee will review current residents BIMS to ensure if there was a cognitive decline they were reassessed for elopement. 3. The nursing staff and social service will be re-educated on the policy dementia -clinical protocol by the Director of Nursing/designee. Social Service will notify the interdisciplinary team when there is a change in resident BIMS to ensure resident is reassessed for elopement risk. 4. The Social Service will audit 5 residents BIMS weekly for four weeks and then monthly for three months to ensure if there was cognitive decline the resident was reassessed for elopement. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.