Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with a history of Alzheimer's disease, depression, and anxiety, and fluctuating cognitive impairment, was able to exit the facility unsupervised. The resident was not located during staff rounds, prompting a search of the building and grounds, and a 911 call. The resident was eventually found by staff in the community across the street and was returned to the facility. The resident stated they were fine and had just been out walking. The incident was reported by a complainant, who stated that the police were called and brought the resident back, although 911 later indicated that no officer responded. Review of the resident's medical record revealed that, despite multiple BIMS scores indicating moderate to severe cognitive impairment, there was no elopement risk evaluation completed until after the elopement event. When the elopement risk assessment was eventually completed, it inaccurately indicated that the resident did not have cognitive impairment or behaviors associated with elopement, despite evidence to the contrary. Subsequent assessments continued to document incorrect information, failing to recognize the resident's history of leaving the premises unsupervised. Additionally, the care plan addressing elopement risk and wandering was not initiated until six months after the resident's elopement. Interviews with facility leadership confirmed that the incident was not reported to the regulatory agency as required. The facility's front entrance was secured with a coded lock, and staff stated that residents needed permission to go outside, with staff supervision provided when residents were out front. However, these measures were not effective in preventing the resident's unsupervised exit.