Failure to Prevent Unescorted Exit of Resident with Depressive Symptoms
Penalty
Summary
A resident with a history of major depressive disorder, cerebral infarction, repeated falls, hemiplegia, and muscle weakness expressed worsening depressive symptoms related to being in the facility. The resident had a moderately impaired cognitive status, as indicated by a BIMS score of 8, and had previously verbalized feelings of hopelessness and a desire not to be in the facility. The care plan included interventions for suicidal ideation, such as social service visits, identifying triggers, and encouraging participation in activities, but did not identify the resident as at risk for elopement. Despite expressing increased depressive symptoms and a desire to leave the facility to the social worker, this information was not communicated to nursing staff or the provider. On the day of the incident, the resident was observed by staff fully dressed and wearing a coat in the lobby, which was unusual for them, but this was not recognized as a potential sign of intent to leave. Later, the resident exited the building unescorted by following a visitor out during a period when the front doors were temporarily unlocked, and was found in their wheelchair at the end of the driveway, visibly emotional and expressing suicidal ideation. Staff interviews revealed that the social worker did not report the resident's increased depressive symptoms because the resident had not explicitly stated an intent or plan to leave. The Director of Nursing Services was unaware of the resident's recent expressions of not wanting to be in the facility. The facility's policy required staff to identify residents at risk for unsafe wandering or elopement, but the resident was not identified as such prior to the incident, resulting in a failure to provide adequate supervision and prevent the resident from leaving the facility unescorted.