Failure to Monitor High-Risk Resident for Elopement
Penalty
Summary
The facility failed to monitor and document hourly rounds for a resident identified as being at high risk for elopement. The resident, who had diagnoses including dementia, alcohol dependence, and heart failure, was assessed as lacking capacity to make decisions and exhibited daily wandering behavior, hallucinations, and a verbalized desire to leave the facility. Despite these risk factors, the resident was not included on the list for hourly rounds, and there was no documentation of monitoring from April to early May. The care plan for this resident specifically indicated the need for constant monitoring due to the risk of elopement, but this intervention was not implemented. Interviews with facility staff, including an LVN, the Director of Staff Development, and the Director of Nursing, confirmed that the care plan interventions were not followed as required. The facility's own policy required identification and monitoring of residents at risk for unsafe wandering or elopement, with care plans to include detailed monitoring plans. However, the lack of documentation and failure to include the resident in hourly rounds demonstrated that these procedures were not carried out, resulting in a deficiency related to accident prevention and supervision.