Failure to Communicate Elopement Risk and Ensure Resident Identification
Penalty
Summary
The facility failed to ensure proper communication and implementation of safety measures for a resident identified as high risk for elopement. The resident, who had diagnoses including parkinsonism, major depressive disorder, dysphagia, and neurocognitive disorder with Lewy bodies, was assessed as lacking the mental capacity to make medical decisions and was severely cognitively impaired. Documentation indicated the resident had a history of leaving the facility and was at risk for elopement, with orders in place for frequent monitoring and the use of a Wanderguard device. However, staff assigned to the resident were not formally notified of the resident's elopement risk, and the resident was not included on the CNA assignment sheet. The CNA caring for the resident was unaware of the purpose of the Wanderguard or the resident's risk status due to lack of communication during shift handoff and morning huddles. Additionally, the resident was observed without an identification wristband on multiple occasions, contrary to facility policy requiring such identification for resident safety. Staff interviews confirmed that the absence of the ID wristband could hinder proper identification and safe care delivery. The facility's policies on Wanderguard use and resident identification were not followed, as evidenced by the lack of communication regarding the resident's risk status and the missing ID wristband, placing the resident at increased risk for elopement and other safety incidents.