Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent elopement for several residents identified as at risk. Resident #22, diagnosed with dementia, was able to exit the facility through the North hall entrance and was found in the parking lot. The resident had previously pulled a fire alarm and attempted to exit the facility, indicating a pattern of exit-seeking behavior. Despite being placed on a code white list and subjected to 15-minute checks, the care plan did not include additional interventions after the initial incident. Resident #95, with a diagnosis of general anxiety disorder, was also able to exit the facility by pressing the door bar for 15 seconds, despite being newly identified as at risk for elopement. The resident was found outside looking for a family member. There was no documented care plan addressing elopement for this resident, indicating a lack of formalized interventions to prevent such incidents. Additionally, Resident #20, who had a cognitive communication deficit, exhibited exit-seeking behaviors by frequently approaching exit doors and attempting to leave the facility. Despite being identified as at risk for elopement, the resident's care plan lacked specific interventions to address these behaviors. The facility's failure to consistently implement and document effective interventions for residents at risk for elopement contributed to the deficiency.