Failure to Identify and Assess Elopement Risk Leads to Resident Exiting Facility Unsupervised
Penalty
Summary
The facility failed to accurately assess and identify the elopement risk for a resident with dementia and severe cognitive deficits, resulting in the resident exiting the facility unsupervised. Upon admission, the resident's elopement risk evaluation was completed and documented as zero for wandering and elopement, based on information from the responsible party who did not disclose a history of wandering. The responsible party later confirmed that the resident had a history of wandering at home, including leaving the house at night, and that alarms and cameras had been used at home to prevent such incidents. However, the facility staff did not directly ask about a history of elopement or attempted elopement as required by the assessment form, instead relying on general questions and the responsible party's lack of volunteered information. The incident occurred when the resident, who had limited mobility and was in a wheelchair, propelled himself outside through an automated sliding door. Staff discovered the resident outside and assisted him back into the building. Video surveillance confirmed the resident exited through the front doors unsupervised. At the time, staff believed the resident belonged in another department and did not initially recognize the elopement risk. Interviews with facility staff revealed that the admission nurse did not directly ask the responsible party the specific question regarding a history of elopement, as required by the facility's policy and assessment form. Instead, the nurse used a more casual approach, which resulted in the omission of critical information about the resident's history of wandering. The resident's Minimum Data Set indicated severe cognitive impairment, further underscoring the need for a thorough and direct assessment process.