Failure to Assess for Psychosocial Harm After Resident Elopement
Penalty
Summary
A deficiency occurred when the provider failed to assess a resident for potential psychosocial harm following an elopement incident. The resident, who had severe cognitive impairment as indicated by a BIMS score of 5 and multiple diagnoses including bipolar disorder, traumatic brain injury, and alcohol abuse, left the facility without staff knowledge. He exited the facility with a church group, attended a service, and was later mistaken for a homeless individual by an ambulance service, which led to law enforcement involvement. The resident was handcuffed, transported to another community due to an outstanding warrant, and later returned to the facility after coordination with local authorities. Upon return, he was found to have redness on his wrists and expressed confusion and fear about the incident. Despite the traumatic nature of the event, there was no documentation that the social services designee (SSD) assessed the resident for any negative psychosocial outcomes related to the elopement. The SSD acknowledged having spoken with the resident after the incident but did not discuss the elopement or provide opportunities for the resident to express his feelings about the event. There was also no evidence of referrals for mental health evaluation, observation for changes in mood or behavior, or review and analysis of mood and behavior documentation in relation to the incident. The provider's policy required the SSD to reassess the resident and make referrals for counseling or psychological/psychiatric consults after an elopement, as well as to document findings and interventions in the medical record. However, interviews with facility staff, including the administrator and LPN, confirmed that these steps were not taken. The lack of assessment and documentation following the resident's elopement constituted a failure to provide medically-related social services to help the resident achieve the highest possible quality of life.