Failure to Supervise and Implement Interventions for Resident with Exit-Seeking Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and implement appropriate interventions for a resident with known exit-seeking and wandering behaviors. The resident, who had diagnoses including dementia, impulse disorder, schizophrenia, and gait abnormalities, was repeatedly assessed as high risk for wandering, with multiple documented high scores on the facility's wandering risk scale. Despite these assessments and documented incidents of wandering and exit-seeking, the resident's care plan was not updated to address these risks until after a significant elopement event. The resident was able to leave the facility on two separate occasions. On the first occasion, dietary staff observed the resident exiting through the front door and found them in the parking lot. The care plan was not updated following this incident, and no new interventions were implemented to address the ongoing risk. On the second occasion, the resident eloped and was found approximately half a mile away from the facility on a busy four-lane road. Staff interviews revealed inconsistent awareness of the resident's elopement risk, with some staff unaware of the risk until after the elopement occurred, and others stating they had not received training on wandering until after the incident. Observations and interviews indicated that exit doors were equipped with alarms and egress releases, but there were reports of alarms malfunctioning or not being heard at the time of the elopement. Staff were unclear on how the resident exited the building, and documentation showed that the care plan lacked specific interventions for wandering and elopement until after the second elopement event. The facility's failure to update the care plan and provide adequate supervision and interventions for a resident at high risk for elopement led to the deficiency.