Failure to Prevent Elopement Due to Incomplete Admission Assessments and Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate monitoring, supervision, and implementation of assistive devices to prevent accidents for a resident with dementia who was newly admitted. The resident, who had a history of impaired cognitive function, risk for falls, and was at risk for wandering, was admitted from a short-term general hospital. Upon admission, the resident was oriented to his room and directed to the dining area for lunch. After lunch, he was last seen at the nurse's station and later in his room unpacking. Within approximately two hours and twenty minutes of admission, the resident could not be located, and a code orange was initiated. The facility did not identify potential hazards or follow internal systems in place to prevent the resident's elopement. The required elopement risk assessment and other admission assessments had not been completed at the time of the incident, as the resident eloped before the four-hour window for completing these assessments. The facility's leadership team had reviewed pre-admission clinical documents but did not find concerning information related to wandering or elopement risk, and the secured unit available was female-only, which influenced the admission decision. The resident was missing for approximately two hours before being located by local law enforcement about a mile from the facility. Interviews with staff confirmed that the resident did not express a desire to leave or appear confused immediately prior to the incident. The facility's policy required an elopement risk assessment upon admission, but this was not completed before the resident's elopement. The failure to complete timely assessments and implement appropriate safety measures resulted in the resident's unsupervised exit from the facility.