Failure to Prevent Resident Elopement Due to Inadequate Assessment and Supervision
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including depression, muscle weakness, difficulty walking, and acute encephalopathy caused by stroke, was admitted to the facility. The resident was documented as confused, disoriented to time, place, and person, and required staff assistance for personal care, eating, transfer, and ambulation. Despite these factors, the facility's elopement assessment rated the resident as low risk for elopement, which was later acknowledged by the Director of Nursing to be inaccurate. On the day following admission, the resident was observed by a licensed nurse standing by her room door with a walker, expressing confusion and searching for slippers. Later that day, a concerned citizen notified facility staff that the resident had been found wandering in the parking lot of another facility across a busy street. The resident had left the facility without staff knowledge, crossed a dangerous roadway, and was found confused and wearing only socks, insisting she needed to buy new slippers. Interviews with facility staff, including the Administrator and Director of Nursing, confirmed that the resident had no wander guard in place due to the inaccurate elopement assessment. Staff acknowledged that the resident was confused, wandered frequently, and required significant redirection and supervision. The facility's own policy required identification and intervention for residents with exit-seeking behavior, but these procedures were not effectively implemented, resulting in the resident's unsupervised elopement and exposure to significant health hazards.