Failure to Implement Elopement Prevention Care Plan and Supervision
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder and psychoactive substance abuse was not adequately supervised, resulting in the resident eloping from the facility. The resident's care plan required Q 15-minute checks for safety and to prevent elopement, but documentation and staff interviews revealed that these checks were not implemented correctly or consistently. On one occasion, the resident was found missing from the facility and was located by staff approximately 30 minutes later down the street with a bag. On another occasion, the resident was found at a bus stop about 20 minutes after being discovered missing. Record reviews showed inconsistencies between the Q 15-minute check documentation and the nurse's progress notes, with the resident documented as "in bed asleep" during times when the resident was actually missing from the facility. The facility's elopement policy required adequate supervision and care in accordance with the resident's person-centered care plan, but this was not followed, resulting in the facility not knowing the resident's whereabouts and failing to prevent the resident from leaving the premises.