Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
A deficiency occurred when a newly admitted resident, who was moderately impaired and had diagnoses including major depression and open-angle glaucoma, was able to leave the facility undetected. The resident was observed ambulating toward an exit and subsequently took an elevator to the first floor, where she exited through a door that was open during the day. Staff, including housekeeping and nursing, attempted to intervene but were unable to prevent the resident from leaving. The resident was not located within the facility or surrounding area despite a prompt search and activation of the facility's elopement code. The resident's admission assessment and elopement risk evaluation classified her as low risk for elopement, and a care plan for elopement risk was not initiated until after the incident. Although clinical documents from the transferring facility included an order for a wander alert device, and the resident had a history of leaving facilities, this information was not fully integrated into her care plan or supervision strategy upon admission. Staff interviews revealed that the MDS nurse did not review prior facility records for elopement risk and that the care plan was only created after the resident had already eloped. The facility's policies required evaluation of elopement risk upon admission and appropriate supervision based on resident condition. However, the resident was able to leave the facility without adequate supervision or intervention, resulting in her being missing for approximately ten hours before being located by law enforcement. The incident highlighted lapses in risk assessment, communication, and supervision that contributed to the resident's undetected exit.