Failure to Identify and Address Elopement Risk for Cognitively Impaired Resident
Penalty
Summary
The facility failed to timely identify and address elopement risks for a resident with severe cognitive impairment. The resident, who had a BIMS score of 7 indicating severe cognitive deficits, was not assessed as being at risk for elopement in the most current available assessment, and no updated elopement assessment was provided during the survey. Despite repeated incidents where the resident accessed elevators and was found on other floors or searching for exits, the care plan did not reflect the resident's wandering or elopement risk, nor did it provide staff with guidance on managing these behaviors. Multiple nursing notes documented the resident's repeated attempts to use the elevator and leave the unit, including instances where the resident was found on different floors and continued to seek exits for extended periods. Staff attempted to redirect the resident without success, and discussions occurred about moving the resident to a secure unit. However, there was no documented follow-up or implementation of this intervention, even though secure unit beds were available in the facility. Staff interviews revealed a lack of awareness and understanding regarding the classification of elopement events, with some staff considering the incidents as AWOL rather than elopement, despite the resident's cognitive impairment. Additionally, the facility's wander guard system was not utilized for this resident, and staff were unsure how it functioned on the unit. The facility had unmonitored elevators and exits, further contributing to the ongoing elopement hazard for the resident.