Failure to Prevent Resident Elopement Due to Inadequate Supervision and Response to Exit-Seeking Behavior
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple dependencies for activities of daily living was able to exit the facility unsupervised by following visitors out of the building. The resident had diagnoses including unspecified dementia, anxiety disorder, and senile degeneration of the brain, and was assessed as having a BIMS score of 6, indicating severe cognitive impairment. Prior to the incident, the resident had no documented history of wandering or exit-seeking behaviors, and her elopement risk assessments indicated the lowest risk. On the day of the incident, the resident exhibited new exit-seeking behaviors, including attempting to use the phone to go home and asking staff what would happen if she opened the door. These behaviors were documented by an LVN, but no further action was taken to notify other staff or implement interventions. The resident subsequently followed visitors out of the facility, and staff only became aware of her absence when contacted by a neighboring facility where she had gone, believing she was going to work there. The facility's failure to provide adequate supervision and respond to the resident's new exit-seeking behaviors resulted in the resident leaving the premises unsupervised. Although the resident was found unharmed and promptly returned, the lack of immediate intervention and communication among staff contributed to the deficiency. The facility's policies required supervision and individualized care planning for residents at risk of elopement, but these were not effectively implemented in this case.