Failure to Prevent Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
The facility failed to ensure that a resident was free from elopement, resulting in multiple incidents where the resident left the premises without authorization. The resident, who had diagnoses including hemiplegia, vascular dementia, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder, was initially assessed as not being at risk for elopement or wandering. However, documentation and staff interviews revealed that the resident was physically able to leave the building independently, and there were previous unsuccessful attempts to elope prior to the documented incidents. Despite the resident's complex medical and cognitive history, care plans and risk assessments did not consistently identify or address the resident's potential for elopement. The resident was able to leave the facility on at least two occasions, once being found by his wife and another time by the director of rehab, both times outside the facility premises in his electric wheelchair. Staff interviews confirmed that the resident was not approved for independent travel and had not signed out, which was required for residents who were not independent travelers. The facility's process for monitoring and preventing elopement, including the use of wander guards and regular checks, was not effectively implemented or updated in response to the resident's changing behaviors and history of elopement. The deficiency was further evidenced by inconsistent documentation in care plans and risk assessments, as well as varying staff understanding of elopement protocols. Staff interviews indicated that while some interventions such as wander guards and increased monitoring were in place, these measures were not sufficient to prevent the resident from leaving the facility unsupervised. The facility's policy required monitoring and precautions for residents at risk of wandering or elopement, but these were not adequately followed, resulting in repeated incidents of elopement for this resident.