Failure to Prevent Elopement of Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with a known history of exit-seeking behaviors and wandering. The resident, who had diagnoses including dementia with behavioral disturbance, depression, hypertension, psychosis, and schizoaffective disorder, was assessed as having severely impaired cognitive skills and was independent in ambulation but required supervision with activities of daily living. Despite multiple documented attempts to elope on a single day, the resident was only re-directed and re-educated each time, with no additional safety measures or interventions implemented to address the ongoing risk. The resident's baseline care plan identified him as a fall and safety risk, with instructions to re-direct him to use a walker and return to his room. However, the admission elopement assessment was not completed for safety measures, and the care plan was not updated to reflect the resident's elopement risk until after the incident. On the day of the elopement, the resident was last seen being escorted to his room, but was later found walking on the street outside the facility by a staff member, who then returned him to the facility. The resident was confused at the time and could not explain where he was going. Interviews with staff confirmed that the resident was known to wander and required frequent re-direction, but no staff reported that he had previously eloped. Observations revealed that some egress doors had added keypads and alarms, but not all doors had delayed egress hardware installed at the time of the incident. The facility's policies required staff to report and prevent resident departures, but these measures were not effectively implemented prior to the resident's elopement.