Failure to Reassess and Intervene for Resident with Exit-Seeking Behaviors Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease, who had a documented history of confusion, agitation, and exit-seeking behaviors, was not re-evaluated for elopement risk nor provided with updated interventions despite multiple documented incidents of attempting to leave the facility. The resident had repeatedly verbalized a desire to go home, attempted to exit the building, and sought assistance from others to leave, as noted in progress notes and staff interviews. Despite these behaviors, staff did not complete an elopement risk assessment or update the care plan to include interventions such as a monitoring bracelet or increased supervision prior to the incident. On the evening of the incident, the resident was observed following staff in a wheelchair and expressing a strong desire to leave. Staff lost track of the resident during a medication pass, and the resident was later found outside the facility after falling from her wheelchair and sustaining a head laceration requiring stitches, as well as abrasions to her elbow and knee. The front door alarm had sounded for several minutes before staff responded, and the resident was not wearing a monitoring bracelet at the time of the event. Interviews with nursing staff and review of facility policy confirmed that the resident's behaviors should have triggered a new elopement risk assessment and additional interventions, but these were not implemented until after the resident's injury. The facility's own policy required systematic monitoring and management of residents at risk for elopement, including timely assessment and individualized care planning, which was not followed in this case.