Failure to Accurately Assess and Supervise Resident at Risk for Elopement
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anxiety, depression, and paranoid schizophrenia eloped from the facility without staff knowledge or supervision. The facility failed to accurately assess the resident's risk for wandering and elopement, as the elopement risk assessment indicated the resident was a low risk, despite documentation of wandering behavior and a history of homelessness, nicotine dependence, and alcohol use. The care plan contained conflicting information regarding the resident's risk factors, and the assessment did not reflect the resident's actual behaviors and history, leading to inappropriate interventions and lack of adequate supervision. On the day of the incident, the resident was last seen on the patio by the receptionist, who did not have a clear line of sight to the front door due to the position of her computer. The receptionist reported that the resident may have exited the facility while she was occupied with other tasks, as a wheelchair was later found near the front door. The LVN on duty last saw the resident in his room, and when the physical therapist went to locate the resident for therapy, he was missing. Staff initiated a search and called a code white for a missing person after realizing the resident was gone. Interviews with facility staff, including the RN and DON, confirmed that the elopement risk assessment and care plan were inaccurate and inconsistent, resulting in a lack of appropriate supervision and interventions. The facility's policies required comprehensive and accurate assessments to inform person-centered care plans and adequate supervision for residents at risk of elopement, but these procedures were not followed, directly contributing to the resident's unsupervised exit from the facility.